This is part 2 of a series following a case. If you missed part 1, please go here and read what we found. 

The patient returns 1 week later and reports being approximately 25% improved. She has been performing her "toes up" exercises while walking all the time. She is having some difficulty still with balance. She has been performing her toe waving exercises a few times daily.

X-rays performed 2/17 reveal screw fixation of the navicular. I cannot find evidence of a previous cuboid fracture. The ankle mortise is clear.

She still has 4/5 weakness of the long and short toe extensors; long greater than short. She has tenderness to palpation along the anterior aspect of the deltoid ligament on the left hand side which is made worse with eversion of the ankle. There is a loss of long axis extension at the talocrural and talonavicular articulations. Less tenderness is noted in the inter metatarsal intervals and the interossei musculature.

There is significant improvement over last time. Lack of fixation of the navicular to other articulations will allow us to perform manipulation/mobilization of the foot. 

I treated with diagnostic manipulation and mobilization of the foot. I reviewed exercises to date and added the shuffle walk exercise. Since acupunture and needling can influence blodd flow (1-4) I utilized acupuncture points stomach 36, spleen 6, gallbladder 41, liver 3, points in the inter metatarsal intervals, bladder 67 and liver 1.Neelding has been shown to improve muscke activation (4-7) so I did origin/insertion stimulation of the long extensors with 3 sets of 10 repetition cocontraction along with origin/insertion stimulation of the short extensors with 3 sets, 10 repetitions cocontraction was performed. She will follow back in approximately 2 weeks because of travel.

So far, so good. I will keep you posted : )

Dr Ivo

1. Sandberg, M., Larsson, B., Lindberg, L.-G. and Gerdle, B. (2005), Different patterns of blood flow response in the trapezius muscle following needle stimulation (acupuncture) between healthy subjects and patients with fibromyalgia and work-related trapezius myalgia. European Journal of Pain, 9: 497. doi:10.1016/j.ejpain.2004.11.002

2.  Cagnie, Barbara et al. The Influence of Dry Needling of the Trapezius Muscle on Muscle Blood Flow and Oxygenation Journal of Manipulative & Physiological Therapeutics , Volume 35 , Issue 9 , 685 - 691

3. Tsuchiya, Masahiko; Sato, Eisuke F.; Inoue, Masayasu; Asada, Akira† Acupuncture Enhances Generation of Nitric Oxide and Increases Local Circulation  Anesthesia & Analgesia: February 2007 - Volume 104 - Issue 2 - pp 301-307

4. Jan Dommerholt Dry needling — peripheral and central considerations Journal Of Manual & Manipulative Therapy Vol. 19 , Iss. 4,2011

5. Zanin, Marília Silva et al. Electromyographic and Strength Analyses of Activation Patterns of the Wrist Flexor Muscles after Acupuncture Journal of Acupuncture and Meridian Studies , Volume 7 , Issue 5 , 231 - 237

6. https://youtu.be/02-M0i6AKAk

7. Fragoso APS, Ferreira AS. Immediate effects of acupuncture on biceps brachii muscle function in healthy and post-stroke subjects. Chinese Medicine. 2012;7:7. doi:10.1186/1749-8546-7-7.