Clinical Reasoning Error

[emad]

Hi all ;

18 years girl , a student nurse in the Hospital where i am working , experienced injury since 8 months , from a galss of window in the school , the imjury was jus above the back of the ankle joint ,superficial to the Achiles tendon ,after that a General Sugeon assessed her as superficial injury , took stitches .

Following that another surgeon reassessed her as Acilles -tendon cut , then referred her to an Orthopedist who confirmed as Achilles -Tendon cut , Telling her go to the Physioherapist ,take 3 weeks of physiotherapy ,if the pain and limping remains ,he will perform an operation.

However , the professor of Orthopedic in all our south of Egypt( who she visited in his private clinic ) told her ,she does not need surgical interference ,saying to her take rest in your home 2 weeks ,no more .

In our Physioherapy departement:
2 new physioherapists , read the reference of Achilles-Tendon cut diagnosis ,worked on the based diagnosis, advised her to perform exercices of Weight-Bearing planter -flexion .

Then :
I saw the case , spent around 1/2 hour collect the data , then assessment .
:arrow: :arrow: :arrow:
Resisted planter flexion :arrow: pain in he gastro region below knee
Resisted toes flexion :arrow: no pain

SLRT :arrow: ++ at 50 degree , pain and tension in boh postrior
aspects of thigh and gastro .

Limping in walking .

Activities ;
putting on high heel shoes
Walking long times in the hospital
Climbing stairs long times .

By the way :
when i concluded o her you need rest , she said he Professor Orthopedist told me to take rest 2 weeks since 3 months , and i stayed in my home for rest but no benefit .

Cheers
Emad

[bernard]

Emad,

The tittle of the subject lets me perplex. You suppose that someone had had a wrong diagnosis and also a wrong physiotherapy treatment?

It is possible with the elements you gave us. It is possible to think that the original injury created some imbalance in gait. Imbalance augmented by high heel shoes. It is possible to think that a compensation occurred in low back with some neural stress?

Try some neurodynamics and see if it has some effects! If it does then continue. In my view, removing high heel shoes will be not a good idea since she may be addicted/habituated to that kind of walking and trying to change this radically may have painful impact?

[emad]

Hi Bernard :

you hypothesised that the referred pain to the thigh is orginated from proximal to distal , as a result of back involving .

But , i think this referred pain going from distal ( site of injury) to proximal .

When i asked her , when you were in rest ,and did not pratice this type of weight-bearing planter flexion ex was there pain ,/tension along the thigh area , she replied no .

I believe , there is neural tension /peripherial neural senstivity as a result of over activities ,walking , planter flexion using the whole body weight .

Another point , i think the high heel shoes put more stress on the gastor& Solues load needed for walking .

I tried with her some neurodynamics (sliders)of both sides DF + planter flex , but no benefit , i believe because of her overactivity.

cheers
Emad

[emad]

Hi Bernard :

Soory , there may be central sensitivity of that case , but what i mean ,it is difficult to put the hypothesis of back involvement as stress .

cheers
emad

[bernard]

Emad,

A central sensitivity is a general definition. Stress is a central process as pain is. LBP is/may be a result of a central process too. A stressed woman may communicate her stress with pain/LBP.
Many depressions have back problems!