Apr 3, 2013

Case of the Week 4-1-13: Fibular Fx Management

image courtesy of radounds.com

This case of the week I saw recently after his fibular was smashed by a rolling log. He was private pay and could not afford to come more than once a week. He was able to completely regain function in 4 visits spread out over 1.5 months.

The eval is as follows


Subjective: Pt reports being hit by a very large rolling log in right fibula, fracturing it on 11/11/12. It was repaired with internal fixation 1 week later. The cast was removed 12/26/12 and he has been in a walking boot since. It has been about 7 week after repair and he is now only using the boot outside of the house. He is eager to get his motion back but is apprehensive to move. He was cleared for PT and AROM, but not full WB. Sx rated 2-5/10 and worse after a day of work. His right ankle swells and has pain at the dorsum of his foot


Objective: fair sitting posture
key: F = functional (WNL), D = dysfunctional, N = non-painful, P = painful, PDM = pain during movement, ERP = end range pain, LRF = lat rotation and flexion, MRE = med rotation and extension

ROM

Hip
Flexion Left FN Right FN
Extension Left FN Right DN, mod
Int Rot Left FN Right DN, mild
Ext Rot Left FN Right FN

Knee
Flexion Left FN Right FN
Extension Left FN Right FN

Ankle
Dorsiflexion Left FN Right DN, sev
Plantarflexion Left FN Right DN, sev

Myofascia: moderate restrictions along lower leg posterior, anterior, lateral patterns, talus and calcaneal bony contours. Skin mobility limited in transverse plane along entire lower leg
Assessment: Signs and Sx consistent with multidirectional dysfunction status post repair and immobilization after fibular fracture


Day 1: The patient was anxious for treatment. He last saw me 5 years ago, when I was using the fascial deformation model and was using quite a bit more force. I explained all of my treatments are using a different model and that nothing would be painful.

To accommodate him, I explained the mirror box and how it was used. We placed his right foot and ankle in the mirror box and I began treating the uninvolved side with IASTM along the medial and lateral lower LE patterns. I then did some grade IV distractions, and posterior glide MWMs to the uninvolved talocrural joint.


To his surprise, after removing the mirror box, he was able to move his ankle actively with much less stiffness, and I was able to passively range him further. He was still severely limited in all planes, but there was more than a 5 degree difference in all planes.


He obtained an EDGE Mobility Band for HEP. I instructed him on wrapping it around his proximal calf and performing tibial IR self mobilizations in half kneel. I also instructed him on wrapping it distally around the tibia, and proximal forefoot and performing repeated end range plantarflexion. He tolerated both of these well.





I generally instruct this with skin to skin, but it doesn't seem to make a difference


passive end range plantarflexion

Day 2: Due to private pay, and the nature of it being a slow responder condition, we both agreed that coming once every other week. He followed up 2 weeks later and was moving quite a bit better. He was no longer apprehensive of the direct treatment to the involved area. However, I still used the mirror box for this treatment to work along the adjacent area where it was tender on the involved side. I wrapped him in the EMB around the proximal tibia and used it for light skin mobilization in the transverse plane, mainly in IR to improve ankle df with one hand. With the other hand, I did a light posterior glide MWM as he was performing the half kneel ankle df stretch.


We progressed to mini squats and mini lunges using the EMB wrapped around the proximal tibia and the distal tibia/talocrural joint (two separate exercises) for 2-3 minutes 3-4 times/day for HEP.


Day 3: The patient was sick, and came in 2 weeks later. He had quite a bit more movement, more than I was expecting. He told me he used the EMB to wrap the talocrural joint and was riding an exercise bike with it on for 10 minutes! I told him that was pretty excessive and I only expected the compression to be worn for 2-3 minutes. Either way his dorsiflexion was now DN, about 10 degrees, and plantarflexion about 40 degrees. Inversion and eversion were much better. Strength and function were much improved as well. However, his surgeon told him he was not removing the final hardware until next September for some reason. We focused on treating the lateral upper and lower LE patterns today with IASTM, which was followed by psoas release, hip LAD and MWM. His right hip rapidly regained most it's missing IR and extension compared to the left side. Instructed on EMB with repeated hip IR in supine; he also felt comfortable using it in the mini squats and lunges.


Day 4: The patient was able to return to work, but still only had about 12 degrees of dorsiflexion and 45 degrees of plantarflexion. However, due to the nature of his work hours and private pay, he decided to make this visit his last. He was extremely compliant and I would have liked 3-4 more visits to progress him to more functional strengthening activities. His hip ROM was now FN in all planes.


I wanted to show this case as a slow responder/MDT dysfunction syndrome that was managed over 6 weeks with very little visits, and mostly self treatment. Additional tools like a mobility band and IASTM, mobilization with movements during the treatments helped him regain more pain free mobility, which helped him exercise during mid ranges at home.


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