Case of the Week 3-11-13: Impossible Radiating Foot Pain | Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

Case of the Week 3-11-13: Impossible Radiating Foot Pain

What do you get when a former patient with lower back pain radiating into her foot with a history of episodes for 10+ years goes to a podiatrist who refers her to a POPTs?

You get a diagnosis of sesamoditis and both practitioners telling her it's "impossible" that her foot complaints are coming from her lumbar spine. Oh yeah, her back hurts too.

She asked to come to me first, but of course the podiatrist would not let her. She decided to return when she realized lumbar extensions were helping her complaints.

Eval as follows

Subjective: Pt reports B foot, leg and and B lumbar complaints intermittent for the past year. In the past 2 weeks Sx have worsened, but were managed previously with lumbar repeated extension in lying. Sx rated 3-5/10 and are intermittent. Sx worse with sitting (lumbar), standing (heels) , wearing normal shoes. Sx better with walking, lumbar extension

Objective: fair sitting posture
key: F = functional (WNL), D = dysfunctional, N = non-painful, P = painful, PDM = pain during movement, ERP = end range pain, LRF = lat rotation and flexion, MRE = med rotation and extension


flexion DN, mild loss, decrease pain with reps, no worse

extension DN, mod loss, centralizes B LE complaints, better as a result

Flexion Left DN Right DN, mod
both ASLR improved with core contraction, indicating motor control/stability

PIVM: DN mod TL and LS with P/A
Assessment: Signs and Sx consistent with chronic lumbar derangement

The repeated motion exam was especially helpful. She had been avoiding most lumbar flexion for a while, after REIL had been helping her complaints. She was limited at first in motion, but her motion improved with RFIS and her lumbar pain also was decreased, but did not remain better. Repeated extension in standing did not appear to be blocked, but knowing this patient is systemically hypermobile, I pushed her mildly into lumbar extension in standing farther and farther. This made her neck hurt (Hx of poor scapula and cervical stability). We then tried modified REIS with her hands on a table, leaning slightly forward. She then brought her hips forward so that her end range lumbar extension still had her hips in neutral. Slight cuing was needed to set her scapula during this motion.

The first two sets, centralized most of the LE complaints, but not her feet complaints. This was verified with a few walks around the clinic after each set. She repeatedly said, "I can't bend back any further." Again, knowing that her thumb could move past her wrist in the hypermobility scale test, I gently cued her hips to go farther and farther in REIS. I performed some MWM with traction to get over the last hurdle of her blocked end range. At this point, she could be dodging bullets in the Matrix. Upon walking after 3-4 sets of REIS to this true end range. She only had a very small point of paraesthesia in her right achilles and all other Sx were abolished.

So much for sesmoiditis. Her extension still felt blocked subjectively, to finish off the treatment, I did some P/A mobs on her T/L and L/S junctions which "felt tight" to her, but rapidly increased in passive play. Afterward, she was able to perform the modified REIS with much less discomfort. She cancelled her following visit, having to work, so it's been over a week since I've seen her... not ideal but I'm confident since she was a former patient, she will have been compliant with her HEP.

Oh a side note... when she said extensions in lying were helping her, she also said she was performing them "all the time." It turns out after further questioning, all the time meant, after work. She got a small lecture for that because she should know better!

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