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Hi all,

I would really appreciate some suggestions regarding a young female patient seen 2 months ago.

13 year old female c/o a painful swollen L/ankle 6/7 months duration which is not swollen in the morning. Her left ankle seems to swell and get painful as the day progresses while she is up and active. she reports no previous trauma of any kind.

No med hx and no medication, pt has no allergies

vascular test - b/pedal pulses palp, capillary refil time WNL, no sign of any other oedema

neurological test- WNL

physical exam - whilst pt leg hangs freely off the examination bench the swelling is visible behind L/medial malleoli, this swelling is also painful to palpate.
buerger's test reduces the swelling along with the pain.

other examinations - the patient was under an orthopaedic surgeon who requested 2 MRI scans (1 with contrast i believe) with no abnormality present. she has no been discharged to 'see how it goes'.

My theory is that this may be some kind of circulatory issue possibly an angioma of some kind, but other than this i'm at a bit of a loss. I told the pt to use a compressive ankle strapping which she reported last week wasn't helping.

i would appreciate your suggestions to help her frustrated mother.

kind regards
s

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It's not a diagnosis but if the pain reduces when the swelling dissipates, try using a graduated compression stocking - European Class II/ UK Class III.

It will reduce swelling more effectively than a compression ankle bandage especially if donned first thing in the morning. If successful, get her to a vascular surgeon.

Doesn't help diagnose but it may treat the symptoms.

Have you ruled out peroneal overusage? I know the orthopod siad the MRIs were normal but ave you tried stress testing them?

Robin

__________________
I see you girls checkin' out my trunks
I see you girls checkin' out the front of my trunks
I see you girls lookin' at my junk, then checkin' out my rump, then back to my sugarlumps

When all you tests are negative for a local problem you need to look somewhere else.

Consider kidney malfunction on that same side.

You can't be serious! No even close to being the reason.

__________________
Craig Payne
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God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.

yes it is possible, as the chiropractor or the naturopath that the failed podiatry patient goes to next.

or ask the 186,000 thousand references on Google

http://www.google.com/#sclient=psy&n...1961ff9 ba31d

You still wrong.
Kidney problems cause BILATERAL oedema.
Left or right sided kidney malfunction causes BILATERAL oedema and NOT UNILATERAL oedema on the side of the kidney malfunction!

Which one of those 186 000 references on Google actually show what you claimed:

__________________
Craig Payne
__________________________________________________ ___________________________________
Follow me on Twitter | Run Junkie
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.

Think of the ankle swelling you'd get if you'd had a kidney removed!

Craig:

I nominate this reply from Toddao as being the first posting for a new thread, Most Bizarre Postings Ever on Podiatry Arena. Should be a great new thread!

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
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Unfortunately you haven't provided us with any information on how much pain this young lady is having or whether she has a pes planus deformity or medially deviated subtalar joint axis in standing or whether the swelling feels organized, is pitting edema, non-pitting edema, discolored, etc.

I'm a big fan of the well-known medical saying: When hoofbeats are heard, think horses, not zebras!

My guess with the limited information provided, posterior tibial tendinitis (horse), not vascular (zebra).

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Scratch that I said this - I read the original posting of L/Medial Malleoli as lateral malleolus, hence the question about peroneal overusage

A case for more information and clearer terminology although probably also a case for paying attention when reading something!

I would go with biomechanical causes too

Physical exam needs more info so look forward to hearing from you

Robin

__________________
I see you girls checkin' out my trunks
I see you girls checkin' out the front of my trunks
I see you girls lookin' at my junk, then checkin' out my rump, then back to my sugarlumps

Dear Team
Some thoughts:
1. MRI with contrast should show any pathology.

2. have you seen the swelling?
if so: hot/cold or normal comaring both legs at the same level.

3. you say it comes on with the day, ie nil on rising, so there is a process that reduces venous return, so:
a. venule problem to veins
b. lymphatic inhibition

I would back 'b'.
ever heard of somato-visceral reflexes?
Here there is a somatic (= body in greek) dysfunction, say an immobile inferior tib-fib joint. Of course this will not show on any radiology.

Basic neurology: one always forgets the sympathetic and parasympathetic chain. These supply the veins and lymphatics etc.

So, if you have a somatic dysfunction you also inhibit the sympathetic and parasympathetic system at that level here S1

once you remove the somatic dysfunction the swelling etc. will go down while you watch because the visceral reflex is now free to work.

This is a common problem I see in the body.

There are 4 possible reflexes:
somato-somato
somato-visceral
visceral-somato
visceral-visceral
They are the forgotten complexes that makes what we are looking at not make sense as to what you are seeing and feeling.

Hope this helps
Regards
Paul Conneely
www.musmed.com.au

Tarsal coalition? Any pain with open chain stj or mtj motion? Any limitation of motion? I have seen similar condition in lateral ankle with resulting RSD. Patient also reported no history of trauma.