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The Active Supination Dorsiflexion Test Guided Therapeutic Intervention for Shin and Calf Pain: a Case Report

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The Active Supination Dorsiflexion Test Guided Therapeutic Intervention for Shin and Calf Pain: a Case Report ISSN: 2572-3243 Sebastian. J Musculoskelet Disord Treat 2020, 6:078 DOI: 10.23937/2572-3243.1510078 Volume 6 | Issue 2 Journal of Open Access Musculoskeletal Disorders and Treatment CaSe RePoRT The Active Supination Dorsiflexion Test Guided Therapeutic Intervention for Shin and Calf Pain: A Case Report 1,2* Deepak Sebastian, DPT Check for updates 1Center for Athletic Medicine & Rehabilitation, Henry Ford Medical Center, Novi, Michigan, USA 2Program Director, Orthopedic Physical Therapy Residency, Institute of Therapeutic Sciences, Plymouth, Michigan, USA *Corresponding author: Deepak Sebastian, DPT, Program Director, Orthopedic Physical Therapy Residency, Institute of Therapeutic Sciences, Plymouth, Michigan, USA Abstract Introduction A 66-year-old male experienced right sided shin and calf Lower leg, shin and calf pain are frequently encoun- pain of an insidious onset. The duration of pain was 3 tered in rehabilitation settings. It is a condition preva- months, aggravated by walking and running. He also report- lent in both active and sedentary individuals [1,2]. Indi- ed resting pain especially during the night. A detail med- ical evaluation ruled out the presence of a blood clot and viduals presenting to a primary care setting with lower electrolyte imbalance. He was diagnosed as having restless leg, shin and calf pain are evaluated for the possible leg syndrome and referred for physical rehabilitation. Initial presence of blood clots [3], chronic exertional compart- examination revealed positive findings of comparable local ment syndrome (CECS) [4], stress fractures [5], and in- tenderness over the right shin and calf. He also present- frequently malignancy [6]. Other causes for lower leg ed with foot pronation that persisted throughout the stance phase of gait. Hence his ability to reverse pronation was and shin pain described in the literature are medial tibi- tested in the standing position. With the knees completely al stress syndrome (MTSS), popliteal artery entrapment extended, he presented with an inability to actively supinate syndrome (PAES) [7-10], peripheral neuropathy, lumbar and dorsiflex the foot on the right side. 8 treatment visits for radiculopathy, spinal stenosis [9,10], dehydration [11], a period of 4 weeks addressed mechanical dysfunction at the ankle, foot, and hip region, comprising, manual therapy, vitamin B12 and vitamin D deficiency [12,13], exertional corrective exercise and pain modalities. Reduction of local rhabdomyolysis [14], restless leg syndrome [15], var- tenderness, and activity related shin and calf pain was ob- icosities [16], congestive cardiac failure [17] and renal served. He reported continued discomfort at rest, but of a pathology [18]. minimal intensity. Additionally, full range of active supination and dorsiflexion was restored in the standing position with The most common etiologies for mechanical lower the knees completely extended. The findings in this case leg pain are extended periods of running [1,7,8] and report describe a common cause of shin pain. It highlights a prolonged periods of standing and walking [19-21]. novel and easily administered method of evaluating limited mobility in the talocrural joint and the relative inability to su- Although a wide range of diagnoses exist for mechan- pinate the foot that could potentially contribute to the symp- ical and activity-induced leg pain, MTSS, CECS, stress tomatology. The test was of value in assessing the need as fracture, nerve entrapment, and PAES are the most well as the outcome of rehabilitation intervention. Further common [1]. Often, more than one of these diagnoses research to examine the diagnostic utility of this method is recommended. co-exist as in MTSS and CECS alongside ankle and foot pain, owing to similarities in their intrinsic and extrinsic Keywords risk or aggravating factors 22[ ,23]. Leg pain, Pronation, Reversal, Supination, ASDT The main aggravator described is the altered foot mechanics during the stance phase of gait. Deviations Citation: Sebastian D (2020) The Active Supination Dorsiflexion Test Guided Therapeutic Intervention for Shin and Calf Pain: A Case Report. J Musculoskelet Disord Treat 6:078. doi.org/10.23937/2572- 3243.1510078 Received: May 27, 2020: Accepted: June 27, 2020: Published: June 29, 2020 Copyright: © 2020 Sebastian D. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Sebastian. J Musculoskelet Disord Treat 2020, 6:078 • Page 1 of 9 • DOI: 10.23937/2572-3243.1510078 ISSN: 2572-3243 in normal foot and ankle mechanics have been de- tion [34,35,38]. Thus, this case report aims to highlight scribed as causes for mechanical shin, leg, and calf pain the ability of contractile structures to be able to initiate [24,25,20]. Literature describes a correlation between the windlass mechanism and the reversal of pronation, lower leg, shin and calf pain and hyper pronation. In a namely, the foot intrinsics, invertors and dorsiflexors of study that prospectively examined the gait-related risk the foot and ankle [26]. Optimal strength of these mus- factors for exercise-related lower leg pain (ERLLP) in a cles is essential for the normal functioning of the foot young, physically active population, subjects showed and ankle. significantly increased pronation, accompanied by more pressure underneath the medial side of the foot Case Description [20,24,25]. These studies describe pronation as in- History and clinical findings creased ankle plantar flexion from mid-stance to toe-off A 66-year-old retired male who experienced symp- and less ankle inversion at the end of stance and early toms of right sided shin and calf pain, is presented. swing phases. These two features favor the presence of The pain was reported to have started gradually over prolonged pronation and the inability to reverse into an 8-month period, following bouts of regular 3-5-mile supination to offer a rigid lever for push off [26]. Per- walks and light running. Symptoms began towards the sistent rearfoot plantar flexion during gait increased de- end of his walking sessions and lingered for a few hours. mand on the anterior compartment musculature during He also reported pain and twitching during the night- ambulation, resulting in pain and dysfunction [20,27]. time disturbing sleep. He had worked as a salesman and For much of the diagnoses of lower leg pain described has been retired for 3 years. He reported his symptoms above, the management and reversal of prolonged pro- to his primary care physician. He had a doppler study nation of the foot during the stance phase of gait has [36] and an X-ray which revealed negative findings. His been advocated, with favorable outcomes [28,29]. The blood profile was unremarkable with normal findings reversal entailed dorsiflexion of the talocrural and in- in electrolyte values [11]. He was a recovering alcohol- version of the subtalar joints, to elevate the medial lon- ic and was on anti-depressants. He presented no other gitudinal arch [27,53,54]. relevant medical history. Evaluation methods described in the literature to identify pronation have been both qualitative and quan- Activity especially extended periods of standing and titative. Navicular drop, subtalar neutral, windlass test, walking typically increased his pain intensity. He report- observing for the presence of a flattened medial lon- ed a relative decrease in symptom intensity with rest gitudinal arch and gastrocnemius tightness associated and occasionally felt no pain. His pain intensity was with limited dorsiflexion and are some of them [30-32]. 7-8/10 on the Numerical Pain Rating Scale [37] at its While a single method of assessment may not improve worse and 2/10 at best. His primary care physician diag- the statistical likelihood of the presence of pronation, a nosed his condition as restless leg syndrome and muscle cluster of findings may offer more validity. This case -re pain and prescribed pain medication. He was also re- port suggests a novel and easily administered dynamic ferred for physical rehabilitation. clinical test that may be added to the cluster, the ac- Testing tive supination dorsiflexion test (ASDT). It is proposed that the ASDT may be sensitive to the patho-mechanical The assessment and testing described in this section challenges that occur during the stance phase of gait in was done prior to treatment intervention. The patient the presence of prolonged pronation or in the absence was seen to be independently ambulant and did not of reversal of pronation. The test aims to capture the exhibit an antalgic gait. In standing, he presented with inability of the foot to be able to reverse into supination a complete loss of his medial longitudinal arch bilater- in preparation for propulsion [27,53,54]. ally. In the standing position, on observation from the posterior aspect he presented with calcaneal eversion. While pronation has been described to cause lower On observation there was no swelling or discoloration leg symptoms, studies have suggested that muscle im- of the lower leg with intact dorsalis pedis and posteri- balance between the invertors and evertors, in the ab- or tibial pulsation. He reported comparable discomfort sence of prolonged pronation, also cause similar symp- and pain over the anterior and lateral shin area and over toms [33]. MTSS may occur without pronation indicators the mid-calf region. He also reported comparable pain like medial longitudinal arch deformation or navicular over the medial tibial region. Passive dorsiflexion was drop. In such cases, one of the causes described is the limited at 10 degrees on the right side. Active inversion strength disbalance of the invertor and evertor muscles was also terminally restricted on the right side. Plantar in favor of the evertor muscles. It may be of value to flexion and eversion were full and free. know that inversion is a component of supination and a lack thereof can favor dysfunctional pronation [33].
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