Case Study – Logan Rees

45mins Physiotherapy Initial 01/02/18

Raul’s Account: “Patient attended the NHS in 2014 due to a sudden and constant pain underneath the first toe, beginning of the first phalange, on the right foot, with a mild swollen Metatarsophalangeal joint. He could not run because of the pain. After several tests there was still no diagnosis for his pain. He was then seen by a private Physiotherapist who did massage and exercises for the calf and recommended a steroid injection to ease the pain. He received this privately in December 2015. Logan found the injection lowered the pain allowing him to start running again in March 2016 but not without some discomfort. He has been unable to get this injury completely resolved.

Logan finds that self-massage on the area with a spiky ball helps as well as running will stiff shoes with good support. Soft shoes seem to make it worse (they allow more toe movement).

I could see that swelling was present and that the toe was externally deviated (Mild bunion). I found as well a great deal of tension on all lower leg muscles, especially on the 1st toe flexors on the right, making it slightly stiffer than on the other foot. Pain was noted when running and on direct touch on the insertion of the Flexor Hallicus Brevis.”

Diagnosis by Raul: Tendinitis of the Plantar Flexors of the 1st toe on the right foot.

Treatment: Massage to the calve muscles

Home care Advice: Specific stretches for Gastrocnemius and Soleus to release tension on the specific tendon causing the pain.

Logan’s Account: “During the first appointment with Raul, we discussed my injury history with particular focus on the long-term foot/toe injury that prevented me from running from May 2014 to around March 2016. Raul had some ideas on how to treat this and he also took some photos to show the extent of the swelling on my right foot. He thought with treatment that the excess skin might become reabsorbed and my feet would end up similar sizes again. In the first session, Raul gave me a short massage on my upper calf. He also showed me some specific stretches to work on for next time to generally loosen my calf so that he could try to release the tension on the specific tendon that was causing pain.”

 

60mins Sports Massage 05/02/18

Raul’s Account: “The tension on the calf muscles has improved due to the stretching he has been doing. Logan mentioned the pain has been slightly better as well.”

Treatment: Mobilisations on the right foot and toe and massage on all right lower leg and foot muscles, with special focus on the 1st toe flexors.

Home Care Advice: Stretches for quads and hamstrings to help ease the tension further and ensure he was stretching other muscles correctly and targeting the right fibres.

“Logan noted he felt a bit tender from the massage on the calf, but the pain was a bit better on the toe and the foot felt looser. The toe was notably less sensitive too.”

 

60mins Sports Massage 14/02/18

Raul’s Account: “No major change noted from Logan when running, has been feeling good lately. The 1st toe is feeling more relaxed and flexible but he has been feeling some tension in the calf.

I found that the tension was coming from previous tension, now evident, on the outside of Soleus. I showed him how to stretch those soleus’ fibres plus the flexor of the 1st toe.”

Treatment: Massage on the Soleus, 1st toe long flexor as well as its short flexor and Adductor. Stretch on the iliopsoas, which was increasing the pressure on the inner leg. After the treatment there is no pain by pressure on the toe anymore, just some pain when doing edge extension with the ankle in complete dorsi-flexion. The swelling has gone but the deviation is still present.

Home care Advice: Still remaining tension on soleus. If not able to relieve it with stretches and the spiky ball he is to come back in 2 weeks, if everything is feeling ok then he updates me by email in 2 weeks and the next appointment is scheduled for 4 weeks’ time.

Logan’s Account: “In the second and third sessions, Raul firstly further loosened my calf as well as massaging the muscles in my foot. In the third session, my calf muscles were sufficiently loose so that only the very tight tendon running down the length of my calf remained tight. That third session was easily the most painful hour of massage I have ever experienced. Raul’s method of not using any products when massaging meant that there were very specific targets that he would loosen with pressure in one area. This is different to any other massage I’ve had before but the precision was very high and after letting the area recover for a day I found it to be notably looser when stretching. The idea that the pain and swelling in my foot comes from a tightness in my upper calf is not new but this is the first time that a specific area has been targeted as the root of the issue.

At the end of the final session, Raul tested the mobility of my right foot and toe compared with the left. It was a lot better than the first session. Raul left me with further stretches to include in my stretching routine to ensure the area remains loose. He told me to come back again in a months’ time to check on the progress or to contact him sooner if experiencing any problems.”

 

30mins Physiotherapy Follow Up 18-03-2018

Raul’s Account: Swelling has reduced (extra skin visible, it will take a long time to reabsorb) and Logan has noted the pain has gone when running and walking. Only some pain when deeply stretching the toe. This will take a while to completely disappear. I recommended to keep stretching the toe flexor and the rest of lower leg always avoiding the pain, and the residual pain he feels on the end range will go away in 4-5 months.

Due to some extra exercise Logan has felt a bit of tension on upper lateral portion of Gastrocnemius in the right leg but he is stretching it well.

Treatment: Massage on the long 1st toe flexor (is feeling in good condition) and on Gastrocnemius.

Home Care Advice: Be careful with training, not to overdo or add in anything suddenly. Keep on top of stretching and include long duration stretches to lengthen the calves.

Logan’s Account: “In the check-up session one month after the final massages, Raul examined my foot and tested the tension of the previously very hard and tight areas in my upper calf. Since the last session, I had been incorporating more specific stretches that targeted the problem areas, into a daily stretching routine. The area around the big toe was notably smaller and appeared less swollen compared to the previous month. Compared next to the other foot, they looked similar in size and shape. It was quite a strange sight for me as this has not been the case since May 2014. Having been swollen for very nearly 4 years there is quite a lot of loose skin and growth around the area that formed to accommodate the swollen toe. Raul predicted this would be reabsorbed, given time, as the area is no longer swollen. The foot has much better flexibility and the calf was substantially looser. With continued stretching and being careful in not adding any sudden shocks (in training) to the areas, the swelling and pain should not return. Raul also suggested adding some calf lengthening methods with long duration stretches and other exercises.”