I found this case study interesting and beneficial when considering treatment for painful ankles.  The article presents with very vague symptoms with limited objective measures eliciting abnormal findings.  I thought this article showed the importance of assessing joint end feels during standard range of motion assessments.

This article examined a 54 year old male software engineer with chief complaint of right dorsal lateral foot pain described as an ache at the dorsal joint line of the cuboid and fourth metatarsal.  Symptoms were of insidious onset about 3 years ago when hiking.  He noticed the symptoms about 1 hour into the hiking and quickly resolved when he stopped hiking.  The subject continued to hike about 1x/week.  He then noticed an increase in symptoms about 1 year ago due to unknown cause with the symptoms occurring about 10 minutes into walking and took about 30 minutes to resolve.  The subject presented with negative x-rays and MRI’s and did not respond to orthotics or electrical stimulation; all provided by a podiatrist.

Physical therapy examination revealed:

1. Tenderness to the dorsal base of the fourth metatarsal

2. Manual Muscle tests of foot, ankle, knee, and hip to be 5/5

3. Negative ligament stress tests for anterior and posterior talo-fibular ligaments, calcaneal-fibular ligament, deltoid ligaments, anterior interosseus, and medial and lateral subtalar ligaments

4. Gait assessment did not show any obvious deviations or pain

5. Posture did not present with any asymmetries or faults

6. All range of motions were normal at the hip, knee,, ankle, and midfoot but the subject had pain at the end range of nonweight bearing plantar flexion and mid-range weight bearing dorsiflexion.  He also presented with a more firm capsular end feel at end range of nonweight bearing dorsiflexion.

7. Joint mobility of talocrural, tarsal, and metatarsal articulations showed decreased posterior and lateral glides with restricted firm capsular end feel of the talus on the tibia.  All others were normal.

Treatment consisted of a high-velocity low amplitude traction joint mobilization of the talocrural joint causing an audible cavitation and a palpable distraction of the joint.  This improved accessory motion of the talocrural joint, the end feel of joint mobility, and the elimination of pain during range of motion assessment.

The subject was given a home exercise program that consisted of wearing shoes as much as possible during the first week to allow the fourth metatarsal to heal and two exercises: completing squats with proper alignment and then a lunge with the affected leg forward and slight internal rotation of the tibia to promote external rotation of the talus both for 10 repetitions 4-5 times a day.

The subject’s symptoms improved and he was able to return to his activities.

Callan B. Clinical reasoning and multi-modal treatment for dorsal-lateral foot pain: a case study. Ortho Pract. 2015; 27(1): 26-31.