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.