Last week, I was treating another PT's patient with the diagnosis of patellafemoral pain syndrome (PFPS). On this day she was complaining of L lateral foot pain after having to wear heels a couple times during the week. With the location of pain, we should immediately develop multiple hypotheses. The patient's asterisk sign was lateral foot pain/tightness with lumbar flexion while in a half lateral split position.
Initial hypotheses based on pain position could suggest cuboid dysfunction, S1 radiculopathy, Intermediate Dorsal Cutaneous neural tension, peroneal strain, lateral ankle sprain, or more. I immediately found no local pain with palpation or muscle testing (making these diagnoses less likely), so my mind went to the spine. I did have some mild pain recreation with common peroneal neural tensioning, but it wasn't a significant amount. While the patient did have some lumbar mobility restrictions, mobilizing the lumbar spine and performing repeated motions had limited improvement in the asterisk sign. Even though I typically like to start at the spine with treatment, some cases are more peripherally based. At this point I addressed the proximal tib-fib joint restriction due to the proximity of the common peroneal nerve, which has a distal branch known as the Intermediate Dorsal Cutaneous nerve. Still no significant change in the asterisk sign occurred.
Fortunately, earlier this year I took a course on dry needling. One of the things I found most beneficial in the course was learning about trigger point referral patterns. A commonly involved muscle, and the culprit in this case, is the gluteus minimus. While the muscle frequently presents with local pain and a "sciatica-like" distribution, it can also present with lateral foot pain (based on the trigger point charts in our dry needling workbooks). After needling this muscle, the patient's asterisk sign significantly improved and the patient returned this week with no more pain in that foot. The lesson from a case like this is that we should not become overly focused on one body region. While many injuries will respond to treatment through different methods, there are certain injuries that require specific treatment.
-Dr. Chris Fox, PT, DPT, OCS
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