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Puzzling Symptom Set - Looking for answers!

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Old 08-31-2016, 07:26 PM   #1
Join Date: Aug 2016
Posts: 3
patrickcolby9 HB User
Exclamation Puzzling Symptom Set - Looking for answers!

Hi All, I've been having issues with my right foot and ankle and would be grateful for any perspective or input from people knowledgeable about foot/ankle anatomy!

As I was recovering from a 2nd metatarsal stress fracture about 18 months ago, my physical therapist attempted a manipulation to "open up" the ankle joint to hopefully alleviate discomfort. He strapped down the leg and yanked on the dorsum of the foot, pulling distally - I believe that is called a talocrural mobilization. After 2 yanks, my toes suddenly went numb. For about 2 weeks, I had intense burning at the ankle and minimal sensation and muscle control of toes 3-5. The sensation was that toes 3-5 were completely flat, and I couldn't feel them or push off with them.

Over the course of 3 months, some sensation seemed gradually to return to the toes, but the foot has not felt "whole" since the incident. An initial MRI 2 months after the incident revealed a tiny synovial cyst contacting the transiting deep peroneal nerve in the tarsal tunnel, potentially causing entrapment, but that cyst has disappeared since a more recent MRI. Beginning 5 months ago, I re-entered PT (with a different therapist!) and have been working to strengthen the muscles above the ankle, as well as toe exercises to work on motion (dorsiflexion, toe extension - notably, after much work, toe 4 does not fully extend - remains curled as I attempt to extend toes).

After 18 months, I still seem to be having sensation (and even motor) deficits that are causing me great discomfort and weakness/pain. Roughly 1 month ago, two bulges appeared above the lateral malleolus (about 2 inches proximally), and one thought was that scar tissue could be somehow compressing the dorsal cutaneous branch of the superficial peroneal nerve above the ankle. Here are several questions regarding my current condition:

(1) The sensation of "flat toes" 3-5 and weakness at the MTP joints is accompanied by what seems like reduced sensation of the webbed spaces between toes 3-5 (esp. 4), indicating that the intermediate dorsal cutaneous branch of the SPN could be affected. Could compression of the SPN slightly above the lateral malleolus cause this, even though I do have some sensation over the toes and the dorsum of the foot? Could a scar tissue bulge cause this?

(2) PT massage of the space between the bulges above the lateral malleolus results in pins and needles about the entire foot. Is this a clear indication of scar tissue compressing the nerve, and if so, are these bulges the result of an error with the talocrural manipulation 18 months ago?

(3) Toes 3 and 4 (mostly 4) appear not to extend all the way at the DIP joint, leading my PT to believe that I have reduced EDL recruitment. Could damage to the SPN (cutaneous) cause this sort of observation, or would there need to be an issue with the EDL?

(4) When I flex my toes, toe 3 lags and does not quite flex at the DIP joint. Could this be related to the superficial peroneal sensation piece, or would there need to be a muscle deficit? (There is an apparent asymmetry in the muscle tone of the affected foot, where the toes appear to run flat from the foot, without any of the muscle tone on the left side.

(4) A nerve conduction test revealed no noticeable abnormalities of the EDB, saphoneous, or tibial nerves. When I pressed the neurologist on the intermediate dorsal cutaneous branch or the bulges above the lateral malleolus, he said that the testing equipment cannot measure nerves that are that small (I guess the larger common peroneal nerve is the only thing that can be isolated?). Could cutaneous peroneal neuropathy explain the complete set of these observations?

What is perplexing about all of this is that I do have sensation about the dorsum of the foot, and there is no severe foot drop, only tenderness and burning at the ankle. Toes 3-5 don't extend properly (and toe 3 doesn't flex completely), but it seems that a SP neuropathy would not explain these deficits.

I would be grateful for any thoughts on any of this. MRI of the foot and ankle have come back negative!

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Old 08-31-2016, 07:47 PM   #2
Join Date: Dec 2010
Posts: 54
Gerr HB UserGerr HB UserGerr HB User
Re: Puzzling Symptom Set - Looking for answers!

I wish I had the answers you are looking for. I will only say that I too have been a victim in the past of a physical therapist causing harm to my right foot/ankle. He pushed my right foot back too far and did some damage to my peroneal tendon. I was going to podiatrists for 2 years and didn't get any help. Somehow, a recommendation was made to me about a board certified orthopedist who specializes in foot and ankle surgery and he told me there was a tear in the peroneal tendon and I needed surgery. I did the surgery and it fixed the problem. I have since been leery of physical therapists and very cautious about what I will allow them to do on me, and have quit if someone makes me uneasy or even causes a strain. I hope that you can find an orthopedic specialist that is very qualified and can diagnose your problem and you can get the help you need, so that there is no guess work or uncertainty.

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Old 09-02-2016, 05:29 PM   #3
Join Date: Aug 2016
Posts: 3
patrickcolby9 HB User
Re: Puzzling Symptom Set - Looking for answers!

Gerr, thanks so much for your feedback. I so appreciate your well wishes .

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foot and ankle, peroneal nerve, scar tissue, toe

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