I recently worked with a client that had daily foot and lower leg pain for two years. They complained of a feeling of numbness in the toes and aching pain along the outside of the leg below the knee and outer half of the foot. The pain would increase through the day and decrease slightly over night. When the pain finally increased enough to prevent them from working a full shift, the client sought medical attention.
The client related that the doctor had examined the area of pain and then ordered an x-ray of the lower leg and foot. He found no obvious problems on the films and then gave the client a diagnosis of sciatica, which is leg pain caused by irritation of the sciatic nerve. He then prescribed an anti-inflammatory medication as treatment. The doctor explained to the client that the pain was likely coming from a nerve in their back, since there was no evidence of a problem on the x-rays of the leg and foot. If the medication did not work he would provide an injection in the back as the next step.
The diagnosis seemed to have been made by the fact that no finding on the x-ray had given any clue as to the cause of the pain, and therefore it must be caused by a nerve from the back. The client took the medication for two weeks with no noticeable change in the level of pain, so stopped taking it. The pain has slowly increased over the past year, to a point that once at home from work the client places a hot pack on the foot and leg and falls asleep. The heat helps reduce the pain slightly.
When I examined the client’s leg and foot, I found that the area described as being numb seemed to be localized to the distribution of the Peroneal Nerve branches. The client could still feel sensation, but felt it less over those areas. No other areas of the leg or back showed any abnormalities in sensation. There was some tenderness over the insertion point of the muscles that control lifting the front of the foot(Tibialis Anterior), and of the muscles that turn the foot out to the side(Peroneus Longus and Brevis). These same muscles were found to be extremely tight and restricted in their motion. Each of the muscles was tender, and when I pressed on the Tibialis Anterior muscle, the pain recreated the deep pain that the client felt each day. All neurological tests for sciatic nerve irritation did not produce any abnormal findings.
Following the examination, I treated the client with soft tissue manipulation, directed at restoring normal motion to the involved muscles, as well as restoring normal motion to the underlying Peroneal Nerve branches. Following treatment the client felt significant relief from the pain, and improved feeling in the toes and foot. A follow-up conversation a few days later found the client with minimal discomfort at the end of the workday and continued improvement in the sense of feeling in the toes.
This case is an example of the importance of combining detailed anatomical knowledge with a well directed physical exam to find the underlying problem. It also provides a window into some of the limitations of medical technology and the benefits of appropriate manual therapy techniques in treating physical problems. In the end, tightness and restriction of a few postural lower leg muscles led to long term compression and irritation of the underlying nerve branches. Once diagnosed, a simple manual solution was applied to alleviate to pain.
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