PREFERRED PRACTICE PATTERN
A 59-year-old man was brought begrudgingly to outpatient physical therapy by his wife. She reports that he has been complaining that his ankle hurts. She also reports noticing that he constantly holds on to the wall, furniture, or other objects whenever he is walking. The man reports having fallen about 2 weeks ago when his toe caught the edge of the sidewalk, and his right ankle has hurt since then. On examination, the right ankle is discolored and demonstrates excessive inversion on passive testing. Grossly, manual muscle testing of the upper and lower extremities is within normal limits. The man does not have two-point discrimination in his feet, ankles, and up to mid-calf bilaterally. Proprioception is impaired in bilateral feet and ankles. Balance testing reveals loss of balance with feet together and eyes closed on a stable surface and with feet together and eyes open on a compliant surface. He is able to maintain single-leg stance on the left for 2 seconds with eyes open. His right ankle is too painful to perform single-leg stance. Past medical history includes: diabetes mellitus, morbid obesity, and coronary artery disease.
Damage to peripheral sensory (most common) and/or motor neurons
Three major types
Distal, primarily sensory, symmetric polyneuropathy (most common)
Transient asymmetric neuropathies
Most likely due to demyelination, inflammation, ischemia, or infarction from as yet poorly understood metabolic abnormality
Diabetic foot and diabetic neuropathy. Data from Physical activity/exercise in diabetes. Diabetes Care. 2004;27(suppl 1):S58–S62.
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