Gait / Running Injury: Misdiagnosed Big Toe Extensor Hallucis Brevis tear in a distance runner from a simple ankle sprain.
* Sorry for the less than perfect video. Need some editing time. Watch from 0:32 onwards for the topic at hand.
This young man, State caliber cross country runner, came in to see us after some unsuccessful treatment for an inversion ankle sprain several weeks prior. Although his swelling and range of motion had improved he was still having pain despite treatment. On examination it was revealed that there was no loss of integrity of the lateral ligamentous restraints, no joint gapping was noted and the ligaments were non-tender. There was no swelling. Balance was clean. Even the immediate local lateral ankle muscular restraints, largely peronei, were competent with skill, endurance and strength assessment. After further pointed discussion, after the ankle was cleared as a causative /symptomatic generator, we insisted the patient be more specific with his pain region. After requesting he palpate around to focalize the area of complaint this time he pointed not to his lateral ankle but rather pointed to the lateral dorsum of the foot over the fleshy mass of the short extensor muscle group just distal and anterior to the lateral malleolus. Inversion of the ankle was pain free but inversion of the forefoot on the rearfoot reproduced his pain pin point to the EHB (extensor hallucis origin area). Upon reassessing his gait it was now obvious that he was unable to engage the left hallux (big toe) extensors. You can clearly see his lack of toe extension (lift) on the video at 0:32 seconds. When consciously requested to do so it immediately reproduced his pain ! If you look very carefully, that the hallux was not extending during swing phase through midstance contact phases of gait. After specific muscle testing found only the EHB (extensor hallucis brevis) weak and not the EDB at all (extensor digitorum brevis) we began a few minutes of manual therapy to the EHB. Within ~5 -10 minutes the EHB was painfree and he could engage the muscle again actively. The muscle was clearly healed from it low grade strain, he was just unable to reactivate it during the gait cycle. Post treatment, he was able to walk immediately with much less pain and with ability to use the EHB in gait. We followed up a second visit with him but he was pain free and was discharged from care. There were no gait compensations and screens for functional sensory motor compensations were unremarkable. Case closed. Good results come from a precision diagnosis which can only come from a sound base of knowledge of anatomy, physiology and biomechanics .... when it comes to this kinda stuff. Would you have picked this up on someone's gait ? We didn't at first. Use your clinical examination to drive your suspicions in your gait analysis. What you see is not always what you get during gait analysis, this easily could have been a similar presentation of a hallux limitus.
Details, details, details. The devil is in the details, The proof is in the pudding....... etc.
Shawn & Ivo