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Ankle dorsiflexion causes lumbar pain

Discussion in 'Biomechanics, Sports and Foot orthoses' started by David Smith, May 21, 2008.

  1. David Smith

    David Smith Well-Known Member


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    Dear All

    Today I had a customer a male of 60years old who complained of ankle pain and swelling and tightness and lumbar pain. About 8 years ago he has a fall where he landed heavily on the left foot causing ankle trauma (he doesn't remember exactly what, where, why.) Anyhow eversinve his ankle has been painful and swollen. Recent X rays show no notable damage or degeneration. The ankle is equinus and I was going to mobilise it when I noticed that while he was in the sitting position and knee extended IE hip flexed 90dgs, ankle dorsiflexion to end RoM caused sharp lumbar pain at about L5 level. He had previously noted that walking up hill increased back pain. Clearly (I assume) there is a stretching of the Sciatic nerve (lasegues sign) which is restricted from sliding thru the spinal vertebral foramen. Interestingly no other therapist had picked this up. The customer said that straight leg raises tried before did not ellicit the pain. I suspect they did not simultaneously dorsiflex the ankle.

    So my question is:

    I was reluctant to mobilise the ankle before further investigations. Do you think mobolising the ankle and improving dorsiflexion RoM would also release tension on the sciatic nerve or is there any danger of further complicating the condition?
    Are there any tests/imaging you would recommend before proceeding further.

    many thanks Dave
     
  2. Dave,
    Have you slump tested him in ankle dorsiflexion?
    Have you seen the x-rays for yourself?
     
  3. Adrian Misseri

    Adrian Misseri Active Member

    A trauma like that could jam and lock up his left sacroilliac joint, which if never corrected, could be having an effect on his lower back and putting his pelvis out of allignment? Id get a physio to do an assessment first before having a go at the ankle.

    Cheers!
     
  4. tarik amir

    tarik amir Active Member

    Danenberg gave a talk at a podiatry conference in Sydney last week regarding sagittal plane restriction and lower back pain. From what I gathered he tries to mobilise/ improve any sagittal plane restrictions.

    I wouldnt think that gradual ankle mobilisation would cause harm unless it was significantly arthritic due to the trauma and in this case the radiographs are all clear. Mobilisation of the ankle would hopefully allow gradual decrease in neural tightness.
     
  5. David Wedemeyer

    David Wedemeyer Well-Known Member

    David,

    Forgive me if I am incorrect but Lasegue's (SLR) is performed supine and indicates disc herniation or space occupying lesion when in a sciatic distribution into the LE. It is a provocative ortho test for reproducing sciatic radiculopathy via lumbar nerve root tension. It's reliability is sometimes questioned though.

    If he is experiencing low back pain (LBP) and denies radiculopathy in a distribution beyond the knee it really isn't a positive SLR. There is a variation of the SLR seated where the leg is brought to 90 degrees and the neck and trunk flexed in progression as well (the Slump Test Simon indicated). Either way many LBP sufferers with disc involvement are lit up by flexion of the lumbar spine in the sagittal plane (which I know you are already aware) and many of these do not exhibit true sciatica.

    I would venture though that your instincts are correct and that he is experiencing possible disc pathology/derangement and possibly concomitant sacral or pelvic issues. If he had described neuropathy, ankle dosiflexion is likely to increase his symptoms in the LE but not all sciatic patients have a positive SLR on physical exam.

    I would be very interested if anyone has any published studies that increased ankle dorsiflexion can cause LBP.

    I tend to believe he has two separate issues and needs two different providers :cool:.
     
    Last edited: May 22, 2008
  6. David Smith

    David Smith Well-Known Member

    Simon

    1) No, ankle dorsiflexion alone ellicits a severe jump reaction and I thought any further stretch testing might risk axion damage. Ah! I didn't mention on last post he has numb toes 1-5.

    2) No, I agree that seeing the x rays for myself would be better. This complaint was secondary to his chiropody visit and I advised referal to our physio or GP/NHS. However he has previously been thru the latter route and now lives with the discomfort, which of course he would like to be resolved.

    Unfortunately I find few manipulative therapist ever start at the foot or even include it in the rehab program. With my limited manipulative skills I have had a lot of success with ankle and foot mobs (and that is as far proximal as I go) and seems a logical place to start where there are closed kinetic chain disorders.
    At my practice I usually mob the ankle and foot, when necessary, and then pass the patient over to the physio for all other work that may be required.

    My intention was to review at the next appointment and after taking advice and if he has not had treatment via any other medic or therapist I would consider ankle mobs (and possibly orthoses to improve saggital plane progression) and refer to our physio.

    David W Thanks for your reply

    .

    Does LE = lower extremity?

    I don't quite get your point here David, can you explain further.

    This person definently has lumbar pain ellicited by ankle dorsiflexion when the hip is flexed and knee extended. What other mechanism do you think could cause this besides streching of the sciatic nerve?

    Again you appear to be suggesting that the ankle dorsiflexion is not connected to the back pain. Can you explain further?

    Thanks Dave
     
    Last edited: May 22, 2008
  7. kevin miller

    kevin miller Active Member

    David S.

    Go ahead and mobilize the ankle. You are not going to increase the back pain and you may very well reduce the numbeness in his toes. Since he is showing definative increae in back pain with ankle dorsiflexion, you can bet his talus is ant-medial. If he has any FF abduction when standing, there is a good to very good chance he is compressing the tarsal tunnel giving you the numbnes that is crossing two dermatomes. If his toes were from his back you should get decreased sensation along either the L4-5 or L5-S1 dermatomes, which you did not mention. The numbenss pattern doesn't match diab. either, ergo, tarsal tunnel. If you know how to do it, detrotate his STJ at the same time. Bottom line, you are on the right track.

    When peole ask me if I can hurt them doing a foot mob/manip, I ask them if they think I can POSSIBLY generate as much force with my two hands as they can walking or running. The answer is obvioulsy "No, not even close."

    Good, luck,
    Kevin M
     
  8. David Wedemeyer

    David Wedemeyer Well-Known Member

    David,

    What I was trying to say is that the SLR is sensitive but not very specific and that increased low back pain without radicular pain in a dermatomal pattern on SLR is not widely considered a positive Lasegue's Sign (at least not as I was taught in college and not according to the orthopedic spinal docs that I have discussed this with).

    Low back pain patients without radicular pain will often reveal increased pain in the lumbar spine, hip and sacral regions on exam, especially while performing the SLR. This is mechanical low back pain and non-neurologic. This is not to say that there is not disc involvement, ie; derangement or bulging but ankle dorsiflexion does not usually provoke their symptoms.

    Are you familiar with the McKenzie protocol for LBP? Early disc involvement can often be spotted just by having the patient lay prone and prop up on their elbows, arching the low back. If the pain is originally more lateral and tends to centralize to a more medial location after a few minutes n this position, it is quite possible that they have mechanical low back pain caused by disc derangement.

    The really neat trick here is that the treatment is the same as the test!

    Also sponylolisthesis can and does increase in acute flexion. This should be ruled out amongst other causes such as postural syndrome, hip pathology etc.

    Yes by LE I did mean lower extremity. Sorry about my abhorrent acronyms.

    I agree with Kevin that the numbness in all of his toes suggests peripheral involvement such as TTS or possibly a vascular etiology and is crossing dermatomes. True sciatic patients have a very distinct referral pattern consistent with dermatomal distribution (ok, most of the time).

    I don't believe that you can do this patient any real harm manipulating the ankle, but if this were my patient I would consider an ortho eval for the LBP and possibly plain film to start.
     
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