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I apologize for the long post. This is a really fascinating patient that I’ve been co-treating with Myra for a few visits. Would love to get everyone’s opinions on diagonsis and treatment.
25 year old male, graduate student, also works part-time at hospital in administrative work.
Former competitive boxer in college, now currently participates in running (25-27 miles/week), cycling, plyometrics, high level strength training
Referring diagnosis: Lumbar radiculopathy
C/O: constant numbness in R LE, weakness
Location of symptoms: Numbness in right buttock down posterior thigh into lateral lower leg, posterior heel, lateral border of foot, and plantar surface of 3rd-5th digits. Inability to perform single leg heel raise on the right. Currently, does not complain of pain. Numbness is constant, however can “notice it more” with walking > 10 minutes as well as first few minutes in the morning. Eases: crouching position. He also has difficulty with stair negotiation due to lack of calf strength in his R leg.
History of Present Illness: Around six weeks ago, he started having tightness in his right hamstring/IT band that wouldn’t relieve with stretching/foam roll. Within a few days, started having right low lumbar into right buttock pain of moderate-severe intensity. Took ibuprofen but symptoms did not improve. Seeking a more aggressive treatment due to severity of pain, patient went to a chiropractor. An adjustment was performed to his lumbar spine, in which patient noticed an immediate onset of numbness in his foot after the adjustment. Pain did not change and within the next several days, pain moved into his left leg and foot and numbness was still present. He was now experiencing spasms within his leg, most particularly with hamstrings and calves. The pain was so severe that the patient would have to crouch down in the fetal position to provide any sort of relief. Patient made an appointment with an orthopedist and was provided with a corticosteroid medication at that time. Over the next several days, he noticed an improvement in pain to where he no longer complained of pain, however there was worsening of numbness/tingling in his left leg.
PMH: Basketball injury 10 years ago in high school when landed on his left buttock, mild and intermittent L low back/SIJ pain since.
Physical *Asterisks* Signs and Symptoms:
No lateral shift present, no calf atrophy.
Neuro screen: Myotomes = 5/5, except for S1/2 Gastroc 3+/5; Dermatomes = L4 Diminished to light touch, L5 Hypersensitivity to light touch, S2 Diminished to light touch; DTR = 2+, expect for R Achilles 0. Inability to distinguish sharp vs. dull in S1 dermatome.Lumbar ROM:
Flexion: Fingertips to mid chin, tightness in right hamstring/posterior calf. With cervical flexion, ***intense pain into right posterior/lateral lower leg, immediate release upon cervical extension.
Extension: 100%, pain at end range in R lower back radiate into medial buttock
Right sidebending: Fingertips to joint line, painfree
Left sidebending: Fingertips to 1 inch below joint line, painfreeStraight leg raise: 70 degrees hip flexion, worse with cervical flexion and dorsiflexion
Accessory Motion testing: R L4 and L5 hypomobile, slight localized pain, resistance felt before pain. Left lumbar and right L1-3 normal and painfree.Hypothesis after examination: Lumbar radiculopathy with possible lumbar disc herniation at L5-S1
Treatment:
– Manual traction in supine hooklying position // no change in neuro screen or neurodynamic testing, although diminished “uncomfortable” sensation and could notice it less afterwards
– Also felt same relief in prone prop position (lumbar extension), therefore gave to him 5 minutes/day
– Selective positioning using pillows in left sidebending position and instructed patient on teaching his roommate to perform same manual traction using bed sheet at home
– Discussed walking in pool and self-traction on pool edge as appropriate exercise at this time
– Double leg heel raises and single leg eccentric heel lowering, as well as single leg balance at homeFollow-Up: Patient reports that he thinks he is moving better, although no change in sensation or numbness, no change in neuro screen. He also reports that he was at the gym using the foam roll and when he hit a certain spot in his thoracic spine, it sent the same pain into his right leg as when initially had pain 6 weeks prior. It was only when the foam roll was placing pressure on a certain spot, then would immediately diminish when pressure was taken off. Happened two days in a row.
New PMH that patient didn’t mention before: Two previous boxing injuries with severe thoracic pain (last one several years ago). Both happened when he went to punch with his right hand into left thoracic rotation. Immediate feeling of “heaviness” and weakness in right arm, as well as severe pain in mid-thoracic region. Resolved in 4-5 days each.
Lumbar ROM:
Flexion: Fingertips to mid shin, tightness in hamstrings/calf.
SLR: 70 degreesThoracic:
Flexion (tested in seated position): 100%, however increased mild pain in right posterior/lateral calf, worse pain with cervical flexion
Extension (tested in seated position): 100%, painfree
Sidebending: 100%, painfree bilaterally
Accessory Motion Testing:
T4: hypomobile, pain reproduction in posterior/lateral calf
T5: hypomobile, painfree
T6: hypomobile, painfree
T7: hypomobile, painfree
T8: hypomobile, pain reproduction in posterior/lateral calf (earlier into resistance than T4)>> At this point, I felt like I would benefit from some help, so Myra was available for consult.
Treatment after evaluation and discussion:
– Thoracic CPA (cross-hand) technique non-thrust BETWEEN T4 and T7 // increased SLR to 95 degrees and no pain with cervical flexion, hip IR/ADD/ankle DF (just tightness in same area at end range)
– Left side-lying lumbar gapping mobilization in neutral position, then slight lumbar rotation // increased lumbar flexion to 100% and painfreeQuestions for Discussion:
– What are your thoughts on the thoracic spine involvement in his case?– Would you start neurodynamic mobilization with him?
– How cautious will you be for guidance with exercise? Otherwise super fit, young male. Wants desperately to return to exercise and be able to do something.
– What would be your prognosis for return of sensation and/or strength in calf?
– Would you consider performing a thrust manipulation on this patient (despite MOI?)
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Thanks for posting Laura!
Did you slump him after you found the thoracic involvement? Did your primary hypothesis change after the thoracic findings? Did you give him any exercises for his T/S?
1. Sounds like there’s some increase in dural tension in that area (did you re-check cervical FLX/EXT at end range lumbar FLX) and sounds like he responds well to treatment at the T/S. I wouldn’t assume that there’s much more beyond that, besides possibly decreased T/S ROT after those incidents, which very well could’ve let to compensatory increased L/S ROT over the years.
2. I’d base the neurodynamics on irritability and severity and how long it takes for symptoms to subside after he aggravates them. At this point, I’d definitely stick with very low level sliders. How would you rate his SINSS?
3. Especially with someone like him, I’d make sure you’re on the same page regarding his activity level and exercises, just to control variables as much as possible. It sounds like he’s still able to do a lot so I would start him in functional positions and something that still challenges him sufficiently, but definitely with the understanding that he should cut down his own exercises (to a certain extent) so you can figure out whether/how much your intervention changes his symptoms.
4. I think that depends on how quickly he can see improvements. If you treat something and he demonstrates an immediate notable improvement in regards to strength (I’d focus more on that than sensation), that might give you a better idea as to what his prognosis would be. I’d definitely educate him on nerve healing times and how that process can take weeks-months.
5. Certainly not at the beginning; main reason would be that a manipulation seems to have triggered his symptoms. Also, seeing how easily you reproduced distal symptoms with T/S PAs, I’d definitely stay away from Gr V for a while. In the meantime, you’ll have a chance to see how much he associates his onset of symptoms with the chiro’s technique and how he feels about it. Either way, it seems that non-thrust techniques have already improved his symptoms, so I don’t think the risk/reward would make Gr V worth it at this point.
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Laura,
This is an interesting case; thanks for posting!
Seeing that his initial thoracic injury (and I am assuming his recent exacerbation at the chiro) occurred with rotation, have you examined how rotation effects his symptoms?
I certainly think it is interesting that T4 and T8 CPA increase symptoms but T5-7 did not.
As is always hard to ascertain with these board posts, what is this guys psychosocial profile? Kinesiophobia/catastrophizing/excessive perseveration on symptoms?
How does decreased reflexes, myotomal strength and dermatomal sensation affect your decision to implement neurodynamics? For me, the combination of all of these plus neural tension might make me slow to implement neurodynamic exercises. Especially if you are able to affect his neural tension addressing other components (e.g., T spine mobility).
My closing thought is that I would pay close attention to the neurogenic findings – dermatomes, myotomes, reflexes, neural tension. I sure think I would want to see an improvement in these over the course of time in a 25 year old male who had recent changes here. That may take a fair course of time, however I would hope and expect to see a trend of improvement.
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Damn that T4 syndrome – I’d send him to Aaron in Winchester to treat.
Seriously – I’d move slowly with him and give it every chance to heal, as we know the majority of these get better on their own especially in a young fit 25 yo.
I’d suspect a big disc, possibly with extrusion or sequestration; but they heal as well.
Continue to monitor neuro each visit to make sure to progressive neuro changes- especially motor weakness progressing.
I most likely would not thrust, especially that there is a central neuro component; possibly related to old thoracic injury.
Also think all central canals are not created equal.
Like others said regarding neural dynamics, especially with a central component; should be slow/gradual based on irritability and response over the next 24 hours.
Keep him moving in a functional way as we know that helps; MET/pulleys with postural/body mechanic cuing/education to keep irritability low.
Low fear communication/wording, encouragement regarding the healing potential of these tissues – ie. “the annulus is just a ligament just like your ankle ligaments, and you sprained those tissues.”
Thoughts?
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As much as I would like to think that a T4 manip would clear this up, I can not in good faith make my fingers type that. I saw a patient very similar to this when covering for Kyle a couple of weeks ago who had loss of achilles reflex, inability to rise on his toes in weight-bearing, and had not responded to 4 days of a dose-pack. The strong neuro findings which did not respond to treatment were concerning and he eventually had imaging and a 1.4cm hernitation on his S1 root which he had decompressed recently. I would be most concerned with your patients neuro findings and inability to generate a heel raise. O’Sullivan talked about the propensity for larger herniations to heel and this is true for others I have seen (our director’s husband had a 9mm herniation and he responded very well to PT last year and avoided any non-conservative management. However, while he had a very (+) MRI, his neuro status was not as involved as Kyle’s patient or yours.
He obviously has strong neurodynamic findings – SLR, Slump, what sounds like passive neck flexion, etc. Did you do long-sit slump on him since you were interested in his sympathetic chain and T/S involvement?
No doubt that with his history and response to mobilization and treatment of the T/S there might be an additional “crush” in this region. But, I would watch those neuro findings VERY closely and let this guide your treatment.
How long would others wait before making a referral with an absent achilles reflex and inability to complete a heel raise? In an acute situation, Meadows talks about the hours (48-72) you have before cell death occurs. This situation sounds a bit different, but thoughts on this?
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Aaron, I sincerely wish you had not asked that last question as that is what I myself was about to toss up to the board, as I am unsure as to the answer.
The authors of the attached article conclude that it is safe to adopt a wait and watch policy of cases of massive disc herniation if there is any early sign of clinical improvement. NO patients in the study had permanent motor loss; however, they did not examine/report the severity of initial motor loss and the rate at which it recovered. A descriptive study documenting the average time it takes for motor loss to return to normal would be well appreciated if it has not already been conducted.
I have no research to back this up, but my practice would be to give it at least 6 weeks before referring for orthopedic consult. That is, I would refer & probably continue to treat at the 6 week mark if there was absolutely no appreciable motor return.
Other ideas? How long would you wait?
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Great case Laura!
Why was your secondary hypotheses is a disc protrusion? Initially you said a fetal position was relieving. However, thoracic flexion did reproduce his pain. It is odd that a T4 CPA would reproduce the posterior/ lateral calf pain. Did his hypomobile L4/L5 reproduce his pain as well?Due to this patient’s response to increased neural tension I would stay away from putting tension in his neural system. He seems to have a positive response to gapping techniques. I see you did the SLR as a re-assessment, I would also retest myotomes, dermatomes, and reflexes before giving a prognoses for sensation return.
Has he had any imaging done? I wonder why his symptoms started 6 weeks prior. Do you know if he increased his running and on what terrain? Have you tested his L5/S1 mobility and hip extension? A lack of hip extension might be a contributing factor on top of neural tension, hypomobilities, myotomal/ dermatomal limitations, and of course T4 syndrome.
Since he has been to the chiropractor and a grade 5 was not beneficial, I would stay away from it in the beginning. He has had a great response to thoracic mobilizations, and I believe it might be beneficial down the road.
How is his current right LE numbness and tingling sensation? I would love to recheck that post thoracic PA or have him walk up stairs.
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I am with Eric on this one. I tend to refer all T4 patients to Aaron.
I want to also explain the similar patient what Aaron was referring to.
I evaled at 6 5 dentist who had a twist mechanism swinging a bat. It sounded disc in nature with this mechanism but he had trace reflexes and 4 heel raises. 3 days later when Aaron saw him he had no reflex and no heel raises. Things went down hill and his treatment was non aggressive SLUMP position sliders and prone press ups to try to continue centralizing from evalI agree with nick and eric about young a healthy, but when things go south we need to know when you go to next route.
Sounds like your patient is not going either way. May need to see in a week what is going on and decide if you are making an impact.
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Hi all! Excellent discussion! This patient has been very very interesting. I commonly see reproduction of lower quarter symptoms w/ assessment of the thoracic spine, usually when the PT is just pushing well beyond the end range of the segment tested and moving the lumbar spine, but in this case, reproducing a very specific L/S pattern of symptoms from the mid-thoracic spine with very specific central PAIVM in the M/T spine (with consistent response) was pretty bizarre. I was definitely thinking about T4 syndrome (:\), but even more, about Butler’s discussion about tension points and the presence of a ‘double crush’ influence from the t-spine, especially after the emerging thoracic history.
I appreciate the comments about close reassess of the neurological findings – I don’t think that point can be emphasized enough. The consistent reassess of the neurodynamic testing is also an important barometer. Also, in regards to referral to an MD – If this patient was not already being followed by an MD, I definitely would not wait at all. I would start the process of an MD consult, so, if the signs and symptoms deteriorate, or return, the patient is already on the path to further diagnostic testing and establishing a relationship with someone who can get the ball rolling on ECI, or surgery, if ever indicated. I am careful to not be too dramatic about the suggestion, i.e., avoiding feeding fear, but I think it makes good sense.
A couple more points.
I believe the ECI plus PT was shown to have better outcomes than either alone, but don’t recall the results being ‘great’ (that was just Laura having a positive impact on the patient’s psyche!). We will find that study and post it for further discussion.
Also, it is an important role that we play in monitoring the patient’s neurological status so closely. It is a great thing that we are seeing the patient more frequently and can reach out to the doc if the situation starts to rapidly regress. If not for P.T., 3-4 weeks may go by between reassessment of the + neurological findings.
In addition, the communication and relationship with the MD is important! This guy had an EMG and we are scratching our heads about the neurological status and prognosis and don’t have the EMG results. It is important to call the MD and discuss the case. The MD who performed the EMG may have a perspective that would be very helpful and all the best for the patient if the medical team is in communication. Laura will have more on that.
… If a week or two goes by and you have not discussed a case with an MD who is co-treating a pt. with you, pick up the phone. You will learn a lot, they will learn a lot, and the patient will be receiving better comprehensive care.
As Laura mentioned earlier, this pt. was convincing himself to have surgery because he was anxious to get back to vigorous exercise and was losing patience. The point I try to make is that surgery is not like a fast food pick up..you don’t just drive to the second window and pick up your return to full activity. Many believe this is the case. By starting some more vigorous exercise w/ emphasis on neutral spine/no increase in symptoms/emphasis on strengthening w/o increased vertical load on the spine, Laura was paralleling with his goals/concerns and he was able to move on from the mentality of ‘I need surgery so I can exercise’ (not to mention all of the other benefits to adding the exercise…)
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