Archive for the ‘Cases’ Category

Case Study: Foot pain in an avid walker/runner.

Tuesday, June 19th, 2012

Patient is a 57-year-old previously asymptomatic female, avid runner/hiker/walker who developed moderately intense pain in the bottom of her foot/arch that worsened with distance, weight bearing and improved slightly with rest.

General exam observed a slender female 5 ft 4 in, 132 lbs.

She exhibited a mild walking gait deficit that was clearly due to foot pain. Lower extremity examination found a normal ankle and Achilles tendon. The toes were normal without anatomical defects. All three arches were intact with the primary arch being moderately high.

Inspection of the sole identified a prominent marble-size, painful, firm, non-mobile nodule in the mid foot, along the arch. The skin overlying the nodule was reddened.

Compressing and to a lesser extent manipulating the nodule immediately recreated the patient’s presenting pain.

The patient was diagnosed with plantar fibromatosis, which is a fairly uncommon, slow-growing, thickening of connective tissues deep in the sole of the foot. It is a non-malignant condition that is often hereditary.

Bilateral involvement is observed in 25% of cases. Although asymptomatic in the other foot, when checked, indeed a less prominent nodule was identified.

The progress of fibromatosis is quite variable but often is dormant for many years until ‘activated’ by repetitive abrasion and microtrauma from walking and running activity by footwear or lack of footwear that increases pressure on the nodule to the point of pain and nodular growth.

Treatment in this case was straightforward. I instructed her to outline the nodule(s) with a marker and while the ink was still wet, stand in her running shoes. The resultant outline on the shoe’s insoles was cut out to leave a gap allowing the patient to run or walk without the nodules being abraded or compressed.

Early relief was significant, with the patient eventually resuming running and walking without pain.

A two month recheck did not find any significant reduction in the size of either nodule although they remained asymptomatic as long as the modified footwear was worn.

It was later discovered that the patient’s mother had a related nodular formation in the palm of her hand, but none on her feet.

Incidentally the patient went in for a general massage and the masseuse refused the patient’s request to leave the nodule alone, massaging the bottom of the foot to the point of discomfort which persisted for about a day.

Plantar fibromatosis does not respond to massage.

he prognosis is good. I do not expect the size of the nodules to decrease but with good protection the growth rate and pain should be minimal to nil.

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Chronic Neck and Back Pain – a Case of Over “Self-Treatment”?

Thursday, September 29th, 2011

Recently a 23-year-old female patient with no prior history of trauma or related medical conditions presented to the clinic with primary complaint of persistent neck pain and stiffness, headaches and upper-mid back pain, recurring over the last 3-4 years.  She was self-employed, and spent the majority of her day in front of a computer. 

 She had tried PT and massage which were ineffective.  She was working with her family MD on an ongoing basis, had been prescribed a low dose of Flexeril to be taken on the ‘bad’ days.  The MD had recommended an MRI scan of the neck, then referral to a chronic pain center.  However the patient has a large insurance deductible, so could not afford this route.

Examination revealed an otherwise healthy appearing young adult female of normal weight, but with very chronic-appearing, ropy, nodular muscle tissues palpated bilaterally from the upper neck down to the mid-back between the shoulder blades.  The tissues were particular rigid and tender along the lateral and posterior neck, yet the neck range of motion was entirely normal.  Misalignments of the spine were identified, particularly in the upper back, yet the bony segments of the neck were found to be somewhat hypermobile. 

Radiographs obtained from the MD were essentially normal.

Summary:  This patient’s situation is seen with uncommon frequency.  An otherwise young, healthy, non-traumatic patient, but with chronic pain and stiffness.  Further history revealed that the patient had an ‘addiction’ to frequently stretching and pulling on her head and neck to get the bones to ‘pop’.  In fact, the patient reported that as she sat in front of the computer working, it was not uncommon for her to pull on her head and neck every 5-10 minutes.

She was diagnosed with self-induced cervical strain/sprain.  In essence the patient gave herself a mild form of whiplash and was suffering from chonic inflammation and low grade spasm of the muscles, tendons and ligament.

I recommended that the patient immediately decrease the frequency of her self-treatments over time, with a goal of stopping entirely, by explaining that she was damaging her neck tissues by the repeated yanking on her neck.  I advised her that she will likely go through a withdrawal period, of sorts, during which her neck will be even more symptomatic.  To heal her injuries, we initiated her on electical muscle stimulation treatments, along with adjustments of the upper back to the segments that were misaligned.  I briefly considered placing her in a neck brace, but the patient declined.  She was given strengthing exercises.  The outcome of treatment is pending, and much depends upon her own compliance.

Case of the Week – Severe low back degeneration

Monday, August 15th, 2011

55-year-old male patient presents with significant numbness of the outside of the left lower leg and foot, history of falls, mild lower back pain.  Surgical history notable for a disc surgery 20 years in the past, due to lower back and left leg pain. 

MRI and X-rays find severe degenerative arthritis and disc space loss at the two lowest levels in the patient’s lower back, as well as degenerative arthritis in the left knee. 

Physical examination is notable for a man who walks with a very pronounced hitch in his left leg gait.  Also notable for loss of sensation to pin prick and light touch over much of the lateral calf, the outside of the foot and the big toe.  Knee and ankle reflexes are both diminished.  Measurements of the left calf girth confirm loss of mass comparative to right (atrophy).

Referrals are made to neurology for further work-up.  In the meantime it is decided to embark upon a course of conservative care with the stated goal of potentially slowing the progression of the lumbar degenerative disc disease, the resulting atrophy and loss of sensation.

Six visits are scheduled with treatment measures including mild manual (doctor-assisted) traction, massage, mechanical chiropractic adjustments, along with instruction in exercises, diet and stretching.  The patient was advised to lose 10-15 pounds.

Current progress: Now into the third week of care, four visits, the patient has reported feeling intermittent pain in a formerly numb area of his left foot.  His left leg continues to feel week, but he has been able to ride an exercise cycle and is walking 3-4 blocks daily without falling.  These are positive signs. 

 The patient will consult with neurology as recommended, to see what they suggest, but in the meanwhile is gaining strength in his weak, atrophied leg, appearas to be maintaining his health, as well as showing a glimmer of restored sensation, even if it is ‘pain’.

Case of the Week – IT Band Syndrome

Thursday, June 4th, 2009

IT BAND SYNDROME 

CASE: 26-year-old female who developed outside knee pain two weeks prior to her presentation at the clinic for examination.

HISTORY: Recently increased mileage, ran through pain, added bicycling to routine, ran with dog who pulled on lead.  Replaced her high-quality running shoes regularly every 250 miles. 

PHYSICAL: Pronated feet, scoliosis of the lower back.  Tenderness outside of knee.  Tenderness lateral hip and buttock.  Sore when sitting in office chair.

DIAGNOSES: IT-Band syndrome [ITBS], Tensor fascia lata syndrome [TFL], Scoliosis (congenital curved spine), pronated feet, flattened arches.

TREATMENT PLAN: Ultrasound and cross friction massage 3x week for 2 weeks.  Stop all running and bicycling.  Check alignment of foot, ankle, knee, hip and lower back.  Home treatment ice/heat/stretching/strengthening.

OUTCOME: We determined that the patient sustained the ITB injury by increasing her mileage too quickly as well as from running off-balance from a dog pulling on a lead.  She had pre-existing scoliosis as a complicating factor.  We determined that she had a secondary case of TFL syndrome in the same leg, caused by compensating for the ITBS pain and climbing/descending her 2 flights of steps often at home.  Her high quality shoes mitigated the flat feet and pronation problem, so this wasn’t a significant factor. 

With treatment and rest, the ITBS pain resolved in 14 days, along with the TFL which we simultaneously approached with electrical muscle stimulation and restrictions on climbing/descending stairs.  We reintroduced run/walks on a trial basis on day 15 with a 5 minute run/walk.  Progressively adding minutes over the next two weeks, 5 at a time until she reached her goal.

DISCUSSION

Situated as we are on Lake Calhoun, surrounded by miles of running and biking trails, we have the opportunity to see a large number of exercise-related injuries, including what is primarily a running-related injury, IT Band Syndrome. 

Iliotibial Band Syndrome typically is noticed by the runner/walker/hiker as outside or lateral knee pain that occurs during or after running.  While many factors can predispose and/or cause a runner to come down with the syndrome, some of the more common causes we see in the clinic are a sharp increase in mileage, running on uneven surfaces, worn out or improper foot wear and biomechanical issues with the knees, hips and/or the lower back.

Treatment options are many.  Here, we utilize a conservative approach to care, tailoring non-invasive treatment to each individual presentation.

Our typical assessment of the running injury may include:

1) Review of running/training history.

2) Physical examination of the spine, hips and lower extremities to assess for biomechanical problems.

3) Assessment of flexibility, mobility and movement patterns.

Treatment may include:

1) Assessment of foot, ankle, knee, hip and lower back alignment.

2) Ultrasound, massage, cross friction massage, ice, heat and/or additional local therapy measures on the injury.

3) A stretching and strengthening program.

4) Reduced mileage, alternate exercises, cross-training, rest, and a step-wise return to activity.

5) Education.  We make it a priority for our patients to understand the injury and underlying causes of injury.

With our competent assessment and diagnosis, our patients have enjoyed good success with our conservative approach to treating their IT Band, and other exercise-related, injuries.  In most cases we are able to resolve injuries to avoid sending a patient on to more aggressive and potentially difficult treatments including prescription medications, cortisone injections and beyond.  If you think you have IT Band syndrome, or any other injury and you would like an opinion, please contact our office for an appointment.

Remember, this is a case history and general discussion of injury conditions we see here.  It is not to be considered specific advice to follow without proper medical or chiropractic evaluation.