May Question of the Month

MAYqom

Test your OCS and SCS test taking skills with these 2 questions:

Questions are all based on the following case that my colleagues and I published in the Journal of Manual and Manipulative Therapy.

1

Question #1

2

A 23-year-old patient presents to a physician with numbness and tingling in the plantar surfaces of her first and second toes of her right foot.  Symptoms in toes would initially present with walking and running in her toes, but eventually progressed to full lower leg numbness when taking only a few steps.  Symptoms then progressed to the point where walking would elicit severe lower leg cramping which would ultimately force her to stop walking.

What is the most likely diagnosis? 

A. Deep peroneal nerve entrapment

B. Peroneal Artery Entrapment

C. Popliteal Artery Entrapment

D. L4-L5 Disc Herniation

 

 

3

 

What is the most likely diagnosis? 

A. Deep peroneal nerve entrapment

  • For this patient, the physician ordered a MRI which confirmed an osteochondroma over the posterior tibial metaphysis compressing the popliteal artery.
  • What appears to start as nerve pain progresses to cramping which could be due to a vascular issue.

B. Peroneal Artery Entrapment

  • Answer choice B is a good option, but not the best.
  • With a peripheral nerve entrapment you would not suspect entire lower leg numbness.
  • With a deep peroneal nerve entrapment you could experience numbness or tingling in the web scape of the 1st and 2nd
  • Her symptoms started on the plantar surfaces of her first and second toes.

C. Popliteal Artery Entrapment

  • Peroneal artery entrapment is very unlikely since it is a branch of the popliteal artery, and would likely affect only one compartment of the lower leg and not the entire lower leg.

D. L4-L5 Disc Herniation

  • Answer choice D is a good option.
  • If a patient has stenosis due to degenerative conditions or a disc herniation, you could get symptoms into the toes and even neurogenic claudication.
  • However, the patient in this case doesn’t fit those clinical patterns. She’s too young to have lumbar stenosis.

 

4

  • We know that the sciatic nerve comes down from the lumbar nerve roots.
  • And splits into the Tibial nerve and the common peroneal nerve which provides sensory innervation to the anterolateral aspect of the lower leg.
  • The common peroneal nerve then breaks down into the deep peroneal nerve which provides sensory innervation in the web space of the 1st and 2nd toes
  • And the superfical peroneal nerve provides sensory innervation to the anterolateral foot.

5

  • Now, the patient’s primary complaint prior to symptoms worsening was numbness and tingling in the 1st and 2nd
  • The tibial nerve splits into the lateral plantar nerve and the medial plantar nerve.
  • One could hypothesize that the osteochondroma at the tibial metaphysisi affected the tibial nerve more than the common peroneal nerve, since the common peroneal nerve runs more posterolaterall than the tibial nerve.

 

Question #2

6

  • The patient had the osteochondroma resected surgically. She performed a bout of rehabilitation focusing on ROM, Strengthening and balance. She still reported intermittent numbness and tingling in her first two toes.
  • Two years after the osteochondroma was removed.
  • The patient was evaluated by a physician for a new complaint of cramping in right anterolateral lower leg with running less than two minutes.
  • As well as numbness and tingling in her first and second toes.
  • Cramping would worsen with activities such as walking, running or using the elliptical
  • And dissipate with rest.
  • The only relevant finding from the physician’s initial examination was decreased sensation to light touch over the right anterolateral compartment.
  • The physician was concerned with two pathologies: Stress fracture and chronic exertional compartment syndrome. A bone scan ruled out a stress fracture.
  • One-minute exertional compartment testing yielded 36 mmHG in the lateral compartment and 54 mmHG in the anterior compartment.
  • The left leg revealed 31 mmHG in the lateral compartment and 45 mmHG in the anterior compartment
  • Values greater than 30 mm Hg are indicative of chronic exertional compartment syndrome.
  • The patient was then referred to a surgeon.

7

  • The surgeon, noted tenderness along the anterolateral compartments and based on compartment pressure testing recommended bilateral anterolateral fasciotomies.
  • The interesting aspect about this decision is that it appeared the patient was only complaining of symptoms in the right leg.

8

  • Three weeks after the bilateral anterolateral fasciotomies the patient presented to PT.
  • Here you can see the body chart she filled out prior to the visit.

9

  • During the subjective history she complained of some post operative soreness.
  • I clarified all the past medical history which we just reviewed.
  • Her hip ROM and MMT was WNL at the hip knee and ankle.
  • She had trace swelling in the compartments of the lower leg.
  • Otherwise, the examination was insignificant.
  • So, I gave her some general ROM and strengthening exercises, such as bridge, SLR, and a gastrocnemius stretch.
  • While I was printing these exercises for her I had her ride a stationary bike.
  • After I printed the exercises I checked up on her, and she reported numbness and tingling on the planar surfaces of her first and 2nd toes of her right foot.
  • There was no cramping in the anterolateral compartments.
  • At this point, the patient was extremely disappointed because she thought that the surgery would have resolved these symptoms.

10.png

What compartment are the patient’s symptoms associated with?

 A. Anterior

B. Posterior

C. Lateral

D. Deep posterior

 

 

3

 

What compartment are the patient’s symptoms associated with?

 A. Anterior

B. Posterior

C. Lateral

D, Deep posterior

  • The answer is D.
    • The patient’s symptoms of numbness and tingling are associated with the tibial nerve, which run through the deep posterior compartment.

5

  • As we know, the sciatic nerve descends from the lumbar roots down the posterior aspect of the thigh and splits into the tibial nerve and the common peroneal nerve.
  • The common peroneal nerve is associated with the anterolateral compartment, and the tibial nerve is associated with the deep posterior compartment.
  • Based on where the patient’s numbness and tingling is, why would anyone assume that an anterolateral fasciotmy would alleviate these symptoms?

 

As she progressed to more activities… she started to report having numbness with driving and walking in addition to riding the stationary bike.

12

  • I continued to see this patient, and she kept giving more interesting information.
  • For example, she reported that she didn’t notice any symptoms on the plantar surface of her first two toes when walking in flip flops.
  • But she did notice them when wearing running shoes.
  • After this, I developed a new theory.
  • The patient’s symptoms are due to tarsal tunnel syndrome affecting the medial plantar nerve.

 

13

  • Now I decided to dive into the research a little bit more for this patient, and what I found was concerning.
  • Chad cook and his colleagues performed a systematic review on the diagnostic accuracy of foot and ankle tests.
  • And in short, found that most of them have high amounts of bias and poor diagnostic utility.

14

  • So, after looking at the diagnostic utility of these tests, I also found that prevalence of tarsal tunnel syndrome affecting the medial plantar nerve is very low.
  • I decided to assess the lumbar spine.

15

  • Before starting lumbar exam, the patient was sitting on the plinth table
  • And she started to experience numbness and tingling into the plantar surfaces of her first and second toes.
  • When I corrected her posture, her numbness and tingling was gone.

16.png

  • I proceeded with a lumbar spine repeated motions examination.
  • I started with the patient in standing, and she had no symptoms prior to starting the examination. And for her, I could only produce her symptoms after she assumed  slumped position for an extended amount of time.
  • Once symptoms were produced however, they were alleviated with repeated back bends.
  • A really good reference for a repeated lumbar spine examination is an article published by Donelson and his colleagues, where if a patient centralized their symptoms with a certain direction they  are more likely to have a good outcome than those that did not centralize.

17

  • Initially, I was concerned the patient had tarsal tunnel syndrome.
  • After, a Mckenzie based lumbar exam, I felt the patient had lumbar derangement.
  • It’s also possible that the patient had altered neurodynamics proximally at the lumbar spine and distally in the lower leg.

1

 

This is a unique case because it highlights the importance of

  • Performing a proximal to distal examination
  • Ruling out any contributing factor from the spine even in post-operative cases
  • And how knowledge of the nervous system can help with your clinical reasoning

 

 

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