In previous posts, I have discussed the importance of checking the intermediate dorsal cutaneous nerve with inversion ankle sprains. In this post, I will discuss a real patient case that verifies the importance of this assessment. Additionally, I will show you my treatment strategy which decreased her pain.
For the past three weeks I have been treating a USPS mail carrier who injured herself while working on the job. The initial evaluation was consistent with an acute lateral ankle sprain. During the first few visits, I focused on restoring normal joint mechanics, ROM, gait pattern, and strength of the foot and ankle. During her fifth visit, she had made significant progress except persistent pain that ran along the dorsal aspect of her foot. The patient traced a line of pain from her ATFL to the 2nd metatarsal. Immediately, this cued me to assess neural tension. (Anytime a patient traces a line of pain or describes the pain as running, shooting, traveling, I suspect neural involvement.)
The patient had symptom reproduction with peroneal nerve biasing allowing me to rule in neural tension as the source of her pain. Upon further subjective questioning, she reported having a previous history of back pain. I assessed the low back and found hypomobility throughout the thoracic and low lumbar spine. Initially, I chose to perform a gapping manipulation of L4-L5 to mobilize the segments of the superficial peroneal nerve (the proximal branch of the intermediate dorsal cutaneous nerve). This manipulation decreased her symptoms by roughly 70%. Next, I manipulated the thoracic spine and talocrural joints which eliminated her symptoms completely.
Neural tension is a real component of common musculoskeletal injuries. Be sure to check for it in your patients.
For the past two weeks, I have been treating a middle-aged man who sustained a compression injury to his right shoulder/ neck region (unofficially coined the schneck). When I first began treating him, his primary complaint was paresthesias in his right radial three digits with referral up the dorsum of the forearm and posterior arm. He reported a nearly constant dull or "blunted sensation" in those fingers at all times and noticed symptoms increased when looking down while at work (a combined cervical flexion and retraction movement). I was not the therapist who performed his initial evaluation, so I performed a mini-reassessment at my first visit to clear each region. Here are the pertinent positive clinical finding:
Posture: depressed, down sloping shoulders
Range of Motion: shoulder and cervical WNL except decreased R cervical sidebending.
Strength: WNL except minimal Serratus Anterior weakness
Muscle Length: short Latissimus Dorsi bilaterally
Joint Mobility: hypomobility noted in the thoracic spine, CT junction, and R first and second ribs. (Normal mobility noted in the cervical spine)
Neural Tension Tests: negative median, ulnar, radial
Repeated Movements: Symptoms increased with cervical retraction, No change with other cervical movements.
Prior to performing the mini-reassessment, I hypothesized that the patient would have cervical joint dysfunction with underlying neural tension. However, the cervical spine, elbow, neural tension, and glenohumeral joint all cleared. Everything was clearing! How was this guy still having pain!?!?
The answer lies in his posture. His primary complaint of pain occurred while looking down at work and nearly constant decreased sensation. When delving deeper into my subjective history, his symptoms generally increased after several hours of working, not immediately. Clinically, I find that when someone has pain after several hours of performing a task, it is generally a muscle endurance or stability and motor control issue. Muscles can support the body for a period of time without pain, but when stressed past a certain limit, symptoms increase. It is one of the body's protective mechanism responses. In this case, his depressed shoulders were causing problems. The upper trapezius, scalenes, and other cervical stabilizers were putting extra tension on the brachial plexus..
Not Every Patient Needs Scapular Depression and Retraction
My treatment: Thoracic spine, CT junction, and first rib manipulations. Manual therapy restored normal mobility, but had minimal effect on his symptoms. I had him perform wall slides with a chin tuck + Shrug overhead, and he noticed his symptoms gradually decreased. Since this decreased his symptoms, his HEP was Wall Slides + Shrugs 10x/hour while maintaining a neutral cervical spine. I chose this treatment approach because it is imperative to restore a neutral scapular position prior to strengthening. I want to make this distinction because previous therapists had attempted to strengthening his lower trapezius and middle trapezius. They were cueing him into further depression and retraction of the shoulder girdle. Strengthening the scapular stabilizers is generally great, but having this particular patient depress his shoulders further was only creating more tension with each repetition. It is important to get each joint in a neutral posture prior to initiating strengthening. Thus far, within one visit (3 days), the patient noticed that the blunted sensation in his fingers was not longer constant. He continues to have an increase in symptoms with cervical retraction over pressure, but it too is of less severity.
My words of advice
You may not always be able to find a dysfunctional tissue during the evaluation, but first make sure the patient is appropriate for physical therapy and then begin addressing primary impairments. I thought for certain my patient would have underlying neural tension and/or cervical joint dysfunction. These did not play out. I was temporarily stumped so I took a step back, looked at the entire patient, and focused on big impairment: his postural deficits.