Calf And Foot Injury- Crossfit

Abstract

HISTORY: A 51-year-old female presented with three-year worsening left lower leg and foot pain. No injury at time of onset but was active with CrossFit five times weekly. Pain began on bottom of forefoot with radiation through the sole of foot to posterior calf and popliteal fossa. Pain described as 7-8/10 in intensity, constant, sharp/stabbing in nature, with burning sensation on the bottom of foot. Associated with weakness of the left ankle, foot drop requiring patient to wear an ankle-foot orthotic, swelling, and color changes with her foot turning blue/red intermittently. Pain was unrelieved with oral NSAIDS, steroids, and only temporary relief with topical anti-inflammatory gel, heat/ice, deep tissue massage, and dry-needling with physical therapy. PHYSICAL EXAMINATION: Examination revealed skin color changes with blue discoloration of left foot that was cool to touch. Tender to palpation maximally over left gastrocnemius muscle, Achilles tendon, sole and ball of foot; 0/5 strength with left ankle dorsiflexion/plantar flexion, ankle inversion/eversion or great toe extension. Sensation intact to light touch in L2-S2 dermatomes. Reflexes normal and symmetric bilaterally. DIFFERENTIAL DIAGNOSIS: 1.Peripheral nerve damage secondary to entrapment/compression 2.Vascular insufficiency 3.Complex regional pain syndrome TEST AND RESULTS: MRI without IV contrast of left tibia/fibula, foot, ankle: - Mild intramuscular edema within gastrocnemius and soleus, focal fatty atrophy adjacent to medial soleus muscle. Generalized subcutaneous edema throughout ankle. EMG: -No evidence of left lumbosacral radiculopathy, left lower limb mononeuropathy, or large fiber peripheral neuropathy US lower extremity Veins: - No DVT in left lower extremity Ankle brachial index: - Normal arterial Doppler study on the left leg during rest with normal PVR waveforms. NM bone scan: - No abnormal blood flow or blood pool uptake involving the left foot or ankle. Mild radiotracer uptake in left midfoot. FINAL/WORKING DIAGNOSIS: Complex regional pain syndrome TREATMENT/OUTCOMES: 1. Physical Therapy focused on strengthening exercises and desensitization techniques 2. Diclofenac topical gel applied up to four times daily 3. Gabapentin 600mg BID 4. Referral to Pain Medicine for lumbar sympathetic nerve block