Injury to calf: diagnosis?

[nari]

This may be interesting to dissect for neuro-orthopaediphiles:

Scenario:
New walking boots; jumped off a one foot high wall, landed on left foot.
Instant sharp pain in left calf; unable to DF or PF, able to walk, on (L)forefoot only. Pain probably 7/10
After 24 hours - swelling, completely colourless, mostly upper gastrocs.
PROM, AROM still unchanged. Sensation OK, pain ISQ.
After 36 hours - swelling ISQ. Some AROM and PROM of ankle. No bruising of any kind, mild linear tenderness both gastrocs. Pain reduced.
After 48 hours - walking plantargrade with pain. Pain probably 3/10.
Resolved within the next two days.

Treatment was initiated within 24 hours (cautiously!)

What was injured, why no colour in the tissues and what Rx might be tried?

This might be very easy for most, but I am still interested in replies, and more so the thinking behind the replies.

Nari

[kongen]

ISQ = ??

[nari]

Apologies...

ISQ is Latin for "the same (as before)". It is a standard abbreviation in this country for medical documentation.

Nari

[oljoha]

In Status Quo

[kongen]

There is stuff to learn here, so I will bite.

Mechanism of injury: how did he/she land on the left foot, e.g. any twisting movements?

[nari]

No twisting, as the hiking boots were new(ish) with full ankle support. The left foot landed first, almost plantargrade, toe --> heel.

Nari

[TexasOrtho]

Nari. Is dorsiflexion equally painful with knee flexed and extended or is it different? Also did you note anything regarding active or resisted toe flexion?

[nari]

Equally painful at first, and then after a day or so, plantarflexion became less so. Toe flexion? I don't know, not tested.

[TexasOrtho]

Equally painful at first, and then after a day or so, plantarflexion became less so. Toe flexion? I don't know, not tested.

I need to go back and review your initial post, but I assume you've ruled out Achilles tendon rupture? My last post wasn't clear, how about passive toe extension OR resisted toe flexion along with resisted and passive inv/ev. Basically, trying to identify if this is a gastrosoleus vs FHL, plantaris, post tib injury.

Anything significant on palpation today vs upon original presentation? Also age and gender of patient? Any other notable issues in the medical history? Previous LE injuries?

[nari]

This injury was five years ago, but it intrigued me at the time.
No toe movement check - did not seem relevant.
No ruptures of anything of a CT nature evident.
Age: 61, female, no previous injury, nil relevant medical Hx.

Clue: No bruising of any kind.

Nari

[TexasOrtho]

This is interesting. Sensory and motor function of distal LE intact?

[kongen]

Tension strain to tibial or sural nerve? I'm a little puzzled..

[Diane]

TO, what on earth makes you think it's a muscle (mesoderm) at all, let alone which one?

[nari]

Rod,

Sensory/motor function OK

Anders,

Getting closer....

Nari

[TexasOrtho]

TO, what on earth makes you think it's a muscle (mesoderm) at all, let alone which one?

Good Lord Diane...mechanism of injury + age of patient + dysfunction (walking plantargrade). Pain with PF. These are things (all taking place on earth mind you) that could be responsible for the presentation. Hear hoofbeats? Think horses not zebras. If it isn't a horse, time to consider zebras.

Back to you Nari and a more productive conversation. Completely resolved in two days? Sural pathology would certainly start to creep into mind after excluding a err...mesodermal tissue.

[Diane]

Originally Posted by Diane View Post
TO, what on earth makes you think it's a muscle (mesoderm) at all, let alone which one?
Good Lord Diane...mechanism of injury + age of patient + dysfunction (walking plantargrade). Pain with PF. These are things (all taking place on earth mind you) that could be responsible for the presentation. Hear hoofbeats? Think horses not zebras. If it isn't a horse, time to consider zebras.

Back to you Nari and a more productive conversation. Completely resolved in two days? Sural pathology would certainly start to creep into mind after excluding a err...mesodermal tissue.

Hello? The pain was all gone in 6 days. Does that say damaged muscle (mesoderm) to you or merely damage signal (ectoderm)? Speaking of horses...

[TexasOrtho]

Someone really should tweak your meds Diane, you are getting really nasty with me. :D If you want to contribute to Nari's case, you can offer up your ideas. Or you could continue your sophomoric persistence in belittilng others. It's an easy thing to do when you are posting something on the internet vs face to face. Diane, feel free to take your personal issues with me up via pm.


Pain often ceases PRIOR to full resolution of an injury and is not always indicative of healthy "mesoderm". Nari, can you bust a cap in this case and let us know what was going on with the patient?

[Diane]

I will reply to you privately TO.

[nari]

Rod,

Horses are more abundant in the public eye than zebras.
Zebras can't be tamed easily by known methods, so horses tend to 'win' us over. I love horses, but we need more zebras in the field of clinical reasoning.

Anyone else with ideas? Doesn't matter if they seem silly -they may not be silly at all.

Nari

[kongen]

The posterior cutaneous of the thigh covers the upper gastrocs. Was knee flexion/ extension limited/painful in any way? Popliteal cyst?
Anyone have other ideas? :)

[pht3k]

well if we are looking for nerve, maybe if the pain was more medial than lateral, we could think saphenous nerve since both the pf and df were painful. what about éversion?

[bernard]

Shoe!

[Erica]

I agree-boots, tight lacing perhaps? Newish, not broken in, perhaps. Compression injury to sural nerve??
Erica

[nari]

Sural nerve sounds good, but wouldn't a compression injury result in lateral foot signs along with some numbness? There was none of these.

No limitation in knee ROM, except full extension hurt a bit in the calf, maybe due to descent onto foot and the ankle couldn't DF due to the boot....

By day 2 there was some tenderness, primarily central gastrocs and slightly medially. But with respect to the unaffected leg - really minimal tenderness. No sign of popliteal cyst that I could detect.

I'll let this run for a while longer, and will say now, that I was unsure what exactly was the origin of the pain.

Anders, keep thinking neural tension and colourless swelling......

Nari

[Erica]

That is true Nari; but I think sometimes neurological signs may not be so obvious. Another thought is-how did she land? Straight up or in a squat position? Perhaps, sciatic/tibial nerve irritation due to some tensioning higher up the chain?
Erica

[Diane]

Nari, I'd like to have a go at this:
New walking boots; jumped off a one foot high wall, landed on left foot.

Not a very long fall, just one foot

Instant sharp pain in left calf; unable to DF or PF, able to walk, on (L)forefoot only. Pain probably 7/10 defense, not defect..
After 24 hours - swelling, completely colourless, mostly upper gastrocs. So, no broken vascular structures, swelling understandable if venous return is unaided by normal movement, depending on age of patient..
PROM, AROM still unchanged. Sensation OK, pain ISQ. Brain not ready to permit movement yet after one whole day.
After 36 hours - swelling ISQ. Some AROM and PROM of ankle. No bruising of any kind, mild linear tenderness both gastrocs. Pain reduced.
After 48 hours - walking plantargrade with pain. Pain probably 3/10.
Resolved within the next two days. So the whole thing resolved in only 4 days. First read through I misread and thought it had been 6. My bad.

Treatment was initiated within 24 hours (cautiously!)

What was injured, why no colour in the tissues and what Rx might be tried?

Treatment tried: Neurodynamic movement (nerve flossing) - plantar flexion with knee extension, dorsiflexion with knee flexion?
Why no color in tissues? Because there was no damage to any structure, no blood into tissue or skin.
What was injured? Not much of anything. Nociception (I would guess, along fibular nerve's neural tunnel) took care of telling the brain that damage was imminent, brain contracted leg appropriately to protect structure. Neurogenic pain was counteracted with the treatment, problem solved. No need for ultrasound, worrying about muscles, ice, anything. Nada.

Close?

[nari]

Diane,

I agree with everything you stated.

This actually was me, not a patient; and it was pre-ideomotion and pre-DNM days. Initially, I suspected some sort of muscle tear, then decided the sural nerve and maybe its neighbours received a bit of a yank which the boss didn't like.

After hobbling for a day or so, I visited a PT nearby, who indifferently diagnosed muscle tear. When I asked 'why isn't there bruising?' she simply shrugged and said the bleeding was very deep. (???)

So I got 10 mins interferential, 5 minutes US and told to stretch the calf three times a day, and then strengthen, etc etc. I stormed/limped out after paying, very cross. The leg actually felt slightly better for about one hour, then not.

I started neurodynamics: gliding with a bit of tensioning, every waking hour for three minutes. Reduced pain and inc ROM started from there. I started walking in the boots(about 10 miles) after five days; the calf brain grumbled and muttered in their boots, but all was well.

It was another lesson: get back onto the horse as soon as possible after falling off.
At the time I suspected the swelling was due to altered interstitial/axoplasmic flow, but I'm not sure about that.

For about four months after, while walking, the mid/medial gastroc would grumble after 3-4 hours. The neurotag was still active, but shut down politely and hasn't surfaced since.

Nari

[Diane]

Hi Nari - I guessed fibular nerve - you didn't actually say whether the calf pain was medial lateral or in between. I guessed fibular, so now I'll ask you, was outside crankier than the medial, or was the whole thing in a totally contracted state?

It's a good example. Great example in fact, to show what sorts of erroneous conclusions can be jumped to by our PT mesodermal kin, when in fact the nervous system is just trying to do its job of protecting, and lands us in some pain/dysfunction. So, PT lesson: think ectoderm first, especially if there is no apparent discoloration. Try neural glides first, because at worst they'll do no harm, and at best, the condition will disappear.

[nari]

Diane, there was pain and swelling in both gastroc bellies, and after a day or so, it seemed to be more central and slightly medial.

It was an interesting experience; but I still rile a bit about that sports physio who simply relied on traditional thinking ( I should have asked her: had she ever heard of Butler, but I didn't for some reason)
What annoyed me as well is that she charged me full rates, which is something PTs should never do to their colleagues.

Nari

[Diane]

OK, so tibial nerve, probably where it bifurcates, throws off the fibular branch, or else where it dives through the deep fascia to get into the calf. Those grommet holes in fascia - they can really grab a nerve and do a number on its nociceptors.

If she was a sport PT she was probably thinking mesodermmesodermmesoderm, her reasoning only mesodermal, and her operations were strictly protocolesque.

About the full rate charge, here in Can. we don't have any sort of sliding scale for colleagues. I charge full rate, but if the person is a friend and I'm seeing them outside office hours, I might not charge at all.

[Diane]

At the time I suspected the swelling was due to altered interstitial/axoplasmic flow, but I'm not sure about that. I wanted to ask you a bit more about the swelling.
1. Was it visible, or just a "feeling" of swelling?
2. Was it only the "bellies"? (I.e., could the "swelling" have been tonic contraction only?)
3. Was it around the bottom, the ankle? Did the sock top leave a dint?
4. Did the entire lower leg swell in a sausage kind of way?

Just curious. Obviously you had enough circulation happening that the nerve recovered fast, and no bruising = no vascular/capillary rupture/tissue damage.

[nari]

Was it visible, or just a "feeling" of swelling?
Visible and palpable. Soft on palpation, but tense ms underneath (naturally)
Was it only the bellies?
Primarily, and lessening distally.
Was it around the bottom, the ankle?....
Not that I felt or noticed.
Did the entire leg swell?
No. Quite localised, really.

I remember David B talking about axoplasmic leaking into tissues, but cannot recall any more.

Nari

[Randy Dixon]

The problem with a guess study like this is that A) we only have the diagnosis the person providing the study came up with, and no reason to assume that it is correct B) the case is presented with an agenda to match A.

[nari]

Randy,

This wasn't a study; it was a simple exercise in clinical reasoning as to what might be the logical explanation for the presentation.

Can you offer an alternative explanation? I would appreciate your thoughts.


Nari

[Luckbox]

This sounds like a typical gastroc strain, maybe bordering between grades I/II.

I think we're over-thinking this one.

[Erica]

A grade II strain that resolved in 4 days, completely?
Erica

[Diane]

A grade II strain that resolved in 4 days, completely? And one that did NOT require mesodermally oriented treatment? (Erica, I share your incredulity that it was a strain of any mesodermal derivative.)

Makes me think that most "grade I/II" "strains" get overtreated to the point of assault, because clinical reasoning is usually mesodermal first instead of ectodermal first, mesodermal second.

The nerves are the most sensitive structures in the leg, in this case, or in the body in any case, and will react (and then the brain will, by contracting mesoderm for protection purposes) before you have time to think in a fall distance of only one foot.

Neurogenic pain is what most ordinary pain IS.

Unraveling this case backwards, Nari had no pain until the muscles seized up, mechanically deforming the neural structures that sent the message in the first place. It wasn't the muscles that did that all by themselves - they had to have been given an order. But why? because the CNS' (whether it was at cord level or higher) job is to protect the organism, at every level, as best it can, with any and every unique danger that presents, at any time, reflexively. Contraction was the defense, pain was a byproduct of it, not of the fall. Had Nari stepped over a ledge that was 6 feet instead of only 1 foot, then something may well have ripped off its moorings. But even then, she would have had more time to think, and if she had trained to fall, previously laid in another (inhibiting) layer of response called "how to relax and roll when you land, if you fall from a height", that training may have had time to become operational. See how ectodermal derivatives work together?

[Luckbox]

She was still complaining of medial calf pain four months after the injury.

I stated it may border between grade I/II. The two may be clinically indistinguishable.

I don't see how this could be diagnosed as anything but a gastroc strain.

Here's a link. The authors even mention the suspectability of the medial versus lateral head as a site of injury.

http://www.medscape.com/viewarticle/475283_2

[Diane]

Luckbox, the mania to classify has prevented them from considering unique mechanisms of injury. Also, the persistent ortho-med attempt to connect "pain" to "muscle" is a bit erroneous these days.

[Luckbox]

Diane,

Her mechanism of injury is anything but unique. Her entire history is literally pathognomonic for gastrocnemius strain.

I'm not discounting the neurological involvement, but this presentation seems pretty clear-cut to me.

If you've got a hammer, everythings a nail I guess.

[Diane]

Or, if you think everything is a nail, then the only investment you'll ever make is in learning how to hammer.

[Luckbox]

Daine,

This is a classical "tennis leg" injury. Here's a few links.


http://www.southern.usta.com/sportscience/fullstory.sps?iNewsid=46718&itype=3919&icategoryid=395

and


http://rad.usuhs.mil/medpix/tf_case.html?&imageid=19482&pt_id=6992&topic_id=5568&quiz=no#discuss

Do you feel this is anything other than what I stated previously?

Can you walk me through some of your clinical decision making? I'm not being disingenuous here, I'm curious as to how you'd handle a case like this, versus a mesodermalist. (I hope I stated that correctly).

[Diane]

Luckbox, pain and movement dysfunction were Nari's main presenting complaints. Those are what we treat.

My reasoning is based on the IASP definition of pain. Here's the first link (http://www.medscape.com/viewarticle/453496_1) I found that includes it, although the article is talking about neuropathic pain, which is more of a "medical" type of "pain". In any case, the definition states: Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

Note the word "potential". What does "described in terms of such damage" mean? It means by the patient, and shouldn't mean by the practitioner. I.e., a patient will come in and say, "I can't walk. My muscles feel like they got torn when I fell off a ledge."

The first question should be, "How high was this ledge?"
"Torn muscle" is just a metaphor for how they feel. A practitioner shouldn't immediately conclude that a "muscle" has been "torn". That is poor reasoning.

Yet, alas, the ortho/chiro/meso mindset has run with everything being an actual damage and don't fully consider that pain can result from potential damage, as per the definition. The ectodermal derivatives are a signalling system, first and foremost. The NS will signal potential damage (at 270 mph, much faster than Nari's foot came down), and the CNS will devise the best protective mechanism it can come up with.

She does a few neuroglides, reassures her system by delivering oxygen to it "artificially", downregulates the pain from further forward in the system (her attitude, her behavior), then 4 days later, the receptor sites have all changed over and she can walk fine.

My "treatment" would be to teach her about pain, maybe stretch her skin a bit, maybe teach her the glides if necessary. The whole scenario seems simple to me. Why is pain logic combined with mechanism of injury such a hard thing for some to grasp?

[nari]

Luckbox,

Once upon a time and even now, if you went to a doc with LBP, he diagnosed a 'strained muscle'. We now know better than to just advise rest and exercise.
If it may have been a gr 1-2 muscle strain, and people want to call it that, then so be it. Perhaps I made a mistake using the word 'diagnosis'. Clearly, it wasn't a severe injury in any sense of the word, but the end result was pain and dysfunction.
This is what we treat; and having a clue about the origin of the pain helps us do that.
Note I said 'origin' and not 'cause'. I self-treated for pain, knowing the dysfunction would resolve by itself once the CNS calmed down.

Now, there are a few possibilities.
I could have done nothing at all, continued to hobble about and swallow NSAIDS.
I could have done stretches + NSAIDS, plus a regime of exercises.
I could have taken up yoga and ginseng.
Eventually it would have resolved, whatever way.
I chose what I saw to be the most efficient way of resolution. I went to the PT because I thought she would have had some ideas that I hadn't thought of. How wrong I was.

C/O pain four months later? Do you know about neurotags? Check out David Butler's texts.
They pop up at a time when the CNS thinks its organism is going to do something silly again. There is no way that the 'muscle' was not healed at 4 months, if it had ever been damaged in the first place. Surely you don't think that?

Nari

[kongen]

I don't think this is a case of over-thinking. I think this is a case of dissecting traditional reasoning where "pain equals tissue damage" is the dominant thought process with the aid of modern neuroscience. When one starts to get to grips with what modern pain science has to offer (I've just started grasping the basics), there is just no way it will not alter one's view of pain and dysfunction, and it is impossible to go back.

[nari]

Anders,

Precisely. :)

Nari

[Diane]

Anders, well said. Yessssssssss! :thumbs_up

[Erica]

Yep, I agree. I think that efforts at clinical reasoning like this are quite useful and informative.:thumbs_up
Erica

[bobmfrptx]

Diane,
I've had upteem sprained ankles, treated many more. The feelings of being squeezed in a vise which ocurr well after 6 weeks, last seconds to a minute and have no rhyme nor reason are Neurotags? The CNS senses danger and is sending a protective response? Makes perfect sense. Thanks
Bob