One of the most gratifying things we do as physical therapists is to get people back to doing things that they had not been able to do for some time because of injury or illness. This case illustrates how a little creativity and tapping into the patient’s own skill set can result in innovative solutions to challenging problems.
Our patient, who is an avid skier, fell awkwardly and sustained a spiral fracture of his fibula, prematurely ending his season. He had surgery about a week later, and the fracture was repaired with a plate and several screws. He went through rehab throughout the spring, and by the time summer arrived he was feeling well with minimal pain and dysfunction in his ankle.
With the onset of the ski season this year, the patient headed back to the ski hill to make some early-season turns. Having not tried on his ski boots since his injury last season, he noticed significant discomfort when he buckled his ski boots, and when he tried to ski, he found the pain was significant enough that it prevented him from tipping that ski enough to engage the outside edge during a turn.
When he returned to the clinic, we reassessed his strength and range of motion, which had not changed significantly since his discharge back in the spring. There was significant tenderness and hypersensitivity over his hardware, which was much more prominent that it was in the spring, as well as in an area extending about an inch in all directions from the plate.
We then took a closer look at his ski boot and how he interfaced with it. Being a higher-level skier, the patient’s boot was designed to fit very close to the foot, and to be quite stiff when properly buckled. The boot liner had a seam along the lateral aspect that ran right along the plate and over several screw heads in the patient’s fibula. It was designed to be flexible to allow the wearer to walk comfortably with the boot unbuckled, relying on the stiffness of the boot shell to provide support when buckled up. This created very focused points of pressure over and around the hardware in the patient’s leg, which had gone heretofore unnoticed as the patient had not worn anything in the spring and summer that exerted the same amount of clamping force around his lower leg that a ski boot does.
We surmised that after the patient was discharged, the swelling in his lower leg continued to resolve, making the hardware of the internal fixation more prominent, but since he was in looser-fitting shoes, the hyperesthesia never made itself known until he went back into his ski boots. The patient has the strength and ROM to flex his ski boot and get his ski up on edge, but pain is holding him back from executing the motion cleanly.
The solution we came up with is two-pronged: in his PT sessions, we are working with graded exposure, gradually increasing compression over and around his repair, paired with functional movements, so that he will become desensitized to the increased pressure over his fibula, and start to trust that he can put pressure through that area without fear of further injury. Since the patient works in the ski industry, he had access to an alternate set of ski boot liners, which had two important properties: they were stiffer than the stock liners, and also heat-moldable. The inherent stiffness of the liners distributes the force of the boot buckles along a greater amount of surface area in his lower leg, lessening the amount of force in the region of the fixation hardware in his fibula. In addition, the customizable nature of the liner allowed for a pressure relief channel to be molded into the liner itself, right over the protruding parts of the plate and screw heads.
Between the two of these approaches, we hope to get the patient back onto his skis within a few visits, and then be able to use his time on the hill to work on progressively increasing his functional tolerance to loading his ski in turns.
I am glad that we are able to give the patient another option to address his pain and dysfunction, other than contemplating having the hardware removed from his fibula, which might sideline him for a second consecutive ski season.
Sometimes, we need to think outside of the traditional areas of exercise therapy and manual techniques to achieve the best outcomes for our patients. And when we can get our patients to be involved in developing creative solutions to their problems, positive outcomes are much more likely.