Case of the Month

Gentleman in mid 60’s (Mr. J) came to my office on 7/01//19 with Right Side Lower Back Pain (Lumbalgia). Periodically he also experienced pain radiation to the dorsal surface of both feet along 3rd and 4th phalanges and bi-lateral pain and numbness in feet. All his life he worked in sitting position as CPA.

His pain and numbness in feet, which is mostly centered around both greater toes, has 30 years old history after he had Laminectomy to relieve pressure of bulging discs L4 and L5 while he was in his 30’s. Later on the patient had two more surgeries to remove debris from the original back surgery and third surgery to clean up scar tissue.

His recent symptoms were diagnosed by neurologist as not being associated with impingement of spinal nerve on the level of the spine but rather from peripheral nerve compression by muscles. The patient was prescribed Zoloft as a muscle relaxant. He complained that medication did nothing to resolve his pain and cramping but made him “feel sick and psychotic”.

Originally his symptoms began in right leg and foot and after 10 years of on and off “moved to the left”. He clearly remembers that symptoms on the right foot manifest themselves approximately three years after laminectomy for L4 and L5. Over the years the patient was treated by number of physicians and physical therapists but didn’t get any stable clinical results.

For last 8 months the patient had been confined to his recliner and could not even walk around as grocery store without severe cramping in both legs, pain and sensory deficit in feet.

EVALUATION

1. Complaints

His current complains are: pain, on the dorsal surface of his feet more prominent on the right; bi-lateral lower back pain especially prominent on the right; right gluteal pain (the patient said ‘right here in a circle” as he pointed to the area over right posterior superior iliac spine and gluteal area).

1. Evaluation of the lumbar area

First of all, I wanted to rule out acute compression of the spinal nerves in the last lumbar segments. Vertical Compression Test on spinous processes of L4 and L5 didn’t trigger any new sensory abnormalities (pain, burning, tingling, numbness) down to the leg and foot.

My next step was to examine fascial tension in his lower back. Both parts of Kibler’s Technique pointed to severe tension accumulation in the first level of Connective Tissue Zones (dermis of the skin) and second level of connective tissue zones (superficial fascia) on the level L4-L5. I was unable to even barely pinch fold of skin in these areas.

Examination of third level of connective tissue zone (i.e., deep fascia) using Lateral Shift Technique indicated presence of great tension in the deep fascia which separates lumbar erectors from quadratus lumborum muscle. In other words, the patient developed heavy scarification of deep fascia with severe adhesions formed between two muscle layers which replaced normal network of fibrotic bridges with high elasticity.

Next, I tested presence of active trigger points lumbar erectors and quadratus lumborum muscles. The largest tension the patient exhibited in the lumbar erectors and quadratus lumborum. Examination of the periosteum indicated very active periostal trigger points along right iliac crest especially at the insertion of erectors and QL muscles.

However, these local findings in the patient’s lower back can be also results of spinal surgery done more than 30 year ago.

Sensory Test to examine presence of cutaneous reflex zones didn’t show significant differences between right and left sides but this finding was uninformative since the patient was already exhibited profound sensory abnormalities and simply couldn’t differentiate intensity of his sensation during the test application. What was obvious is Dermographism Test. It pointed to severe parasympathetic tone predominance int the lumbar area which was additional indicator of long presence of chronic pain which actively disturbed balance within autonomic nervous system.

1. Examination of the lower extremities

Examination of the gluteal area indicated presence of active trigger points in gluteal muscles especially active trigger point was detected in the right piriformis muscle.

Patient exhibited so significant tension is hamstrings and posterior leg muscles that Compression Test as well as Tinnel’s Test for both soleus canal (for tibial nerve) and tarsal canal (for common peroneal nerve) were very positive.

Thus, it was almost impossible to determine if either the Tibial nerve or Peroneal nerve are compromised or both. So according to Peroneal Nerve Neuralgia and Tibial Nerve Neuralgia protocols recommended by Science Of Massage Institute I need to start with the Piriformis Protocol as I previously ruled out acute disc compression of L4 and L5 spinal nerves.

THERAPY

For the first 5 sessions I used Piriformis Syndrome Protocol suggested by SOMI. However I started with addressing lumbar area concentrating on paravertebrals and QL giving more attention to the right side. During these sessions I also worked on hamstrings, adductors and posterior leg muscles following pathways of sciatic as well tibial and common peroneal nerves. I finished each session with PIR for the QL and piriformis muscles. By the 5^th session I was able to resolve TPs for right QL and Piriformis

Even after 2nd session the patient began to feel less pain and discomfort in lumbar erectors, QL and gluteal muscles.

By 3rd session much of tension in muscles of lower legs was dissipated and I was now able to clearly determine that it was the Common Peroneal nerve part of the Sciatic nerve being compressed by peroneal muscles and tibialis anterior bilaterally. The tension in the soleus canal and consequent tibial nerve irritation was just reflex reaction to the years of chronic pain and tension. Tinnel’s Test was still very positive under the fibular head (for common peroneal nerve) while it was now negative over the soleus canal (for tibial nerve). Also application of electric vibration below fibular head sent clear shock wave all way into toes of right foot. Finally there were very painful periosteal reflex zones formed along the pathway of common peroneal nerve from lateral calcaneus, talofibular ligament and all way along 5th metatarsal bilaterally, but more prominent on the right. Another encouraging factor was that the 3rd session patient complaint of ‘circular pain” in right QL and gluteal muscles became ‘much duller”. I encouraged him to continue homecare stretches for piriformis and right QL.

During following sessions, I began to focus on bilateral application of Peroneal Nerve Neuroalgia protocol while continue to treat tibialis anterior and posterior leg muscles. Tibialis proved to be very tight and almost heavily fibrotic. I included therapy of cutaneous reflex zones with skin friction, pinching, skin rolling along the lateral leg all way down dorsal aspect and toes on both feet.

Mr. “J” has been faithfully seeing me for treatments 2x a week, 3-5 days apart since 7-01-19. He does all his suggested homework exercises with enthusiasm. The following is a list of his many “little victories” he has experienced:

1. By his 6th session Mr. J reports ROM and mobility of ankles “feels more Loose” and felt more improvement in walking after 4th treatment.
2. By 7th session he reported 50 % decrease of tingling in the feet and toes after I started to use engage his periosteal reflex zones with Cyriax’s friction over lateral calcaneus, lateral ankle, talofibular ligament to 5th metatarsal bones in both feet.
3. By 8th session Mr. “J” reports feet get sore but rubbing them bring relief from painful burning. He also notices numbness in both toes start to resolve.
4. By 9th session lesser discomfort and numbness moved from 4th toe to middle toes bilaterally. Walking feels less like “walking on pebbles”
5. By 10th session Mr. “J” able to walk better and “even my wife noticed improvement in gate and walk”. He also notices that “feet feel more like flesh” I observe that once tough fibrotic firmness along peroneal group and tibialis anterior became more pliable. He also reported that during PIR therapy the passive stretching of peroneals and Tibialis Anterior his muscles “has more bounce to it”.

We started to see each other 3-5 days apart week on weekly basis:

1. August 13: Mr. “J” was able to cross an entire store without employing a slow, cautious gate in which he usually curl his toes with each step.Pain is resolved but still has tingles and numbness.
2. August 23: Mr. “J” begins stretching 3 times a day after reviewing proper techniques for homework exercises. His “new favorite hobby is to rub my feet because it feels so good!” I observe that now Trigger Point Therapy require a small fraction of the time to control tension and residual discomfort!
3. September 19: Mr. J played pool for 6 hours! “rubbed my sore feet and went to dinner!”. Some minor flare up was controlled by work on lower back and gluteal muscles bilaterally. Quickly provided TM and passive stretching before resuming PNN protocol.
4. September 23: Mr. J begins planning for more active lifestyle. “I’d like to do something all day” he again requests attention to lower back and gluteal muscles before application of Peroneal Nerve Neurlagia’s protocol.
5. September 30: Mr. J has an active 3-day weekend of “doing too much” yardwork that includes landscaping and next day 6 hours of billiard contest. As a result he had two days of relapse. We were able to quickly control it.

Lately Mr. J reported last remarkable victory: “Ankles feel much better! Feet feel really good!” He now rubs his feet with a gua sha stone, does his exercises and rolls his ankles in circles, “Feels like walking in slippers!”

After consulting with Dr. Ross Turchaninov he suggested to add TENS unit along the strategic points of common peroneal nerve and lumbar decompression by inversion table. Mr. J has accepted these two amendments and had additional improvements!

So how did this all happen? It is my theory that years of sitting at a desk working as CPA and his various hobbies resulted in compression and bulging of disc L4 and L5 which led to laminectomy while in his 30es. Lack of correct soft tissue rehabilitation in combination with consequent spinal surgeries triggered common peroneal and later tibial nerve irritation and adhesions formed between layers of the soft tissues in his lower back, legs and feet. As a result normal mobility between layers was greatly affected additionally contributing to the nerve irritation and ROM restriction. Eventually his symptoms progressed to almost complete disability in both feet. I am sure that it was his right QL which at one point throw off lumbar balance affecting erectors and right piriformis. With time it lead to entrapments of sciatic and later its common peroneal branch.