Neurological Leg Pain

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Hi all I would appreciate any help with this case.

A 25 year old male was referred to me by a physiotherapist. He c/o of pain around the area of Geurdy's Tubercle in both legs, (Left > Right). He is a very active individual and is an active member of The Teratorial Army and frequently participates in long hikes carrying heavy loads. He also cycles and wind surfs. His symptoms have been on going for approx 1 year and seemed to start when he increased his running.

O/e he appears to have extreme tightness in
- hip flexors, piriformis, poas,
- hamstrings, gasto soleus complexes,
- itb tight and weak
- weakness in glut med
- and physio states his core strenght is poor.

Biomechanically in static stance his ncsp is 2 degrees inverted on right and 3 degrees inverted on left. rcsp is 0 in left and 1 degree inverted on right. He has a high tibal varum angle of 7degrees on left and 5 degrees on right. He has a forefoot valgus with a mobile p/f first ray in both feet.
He also appears to have a flexible forefoot equinus bi laterrally.
Gait analysis confirms very supinated rear foot at contact, early forefoot striking and excessive mtjt pronation. He has a very pronunced abductory twist bilaterrally. He appears to pronate excessively into propulsion.
Now, his pain is worse at rest than it is in movement, athough he can run for about 10 minutes pain free before it starts.
Physio reports a positive slump test.
He has been prescibed a full lower limb stretching program and was issued with a semi flexible full lenght pair of orthoses with a heel raise of 1 cm on both and posted to neutral at both rear feet and forefoot valgus wedging. His tibia varum angles were accounted for in his prescription.
His symptoms eased only slightly but he still gets the pain around the lateral knee area. Physio and I agree that his pain must be neurologial in origin but his poor biomechnics are certainly having a major influence.
His orthoses have been adjusted on 2 occasions. I also added some rearfoot valgus wedging bilaterrally to see if this would ease symptoms and his exercise regieme has been modified. No real ease in symptoms. He was prescribed medication by his GP for his neurological pain and this has helped ever so slightly. I have also had him in night splints to try and alleviate his gasto soleus equinus.
One thing that appears to ease symptoms a bit is wearing a higher heeled walking boot with his orthoses. Should I increase his heel raises?

I am at a loss at this time and would appreciate any in put.

Many thanks,
Sean Savage
AKA Footsoldier

 

Sean

I had a VERY similar patient a few years back.
His running style (With a back pack ) was inducing the same pain and we couldn't do anything to fix him. The only way we managed to come up with this diagnosis was by using a 15 camera motion capture system and pre-fatiguing him prior to assessment. AMTI load assessment showed COP accelerating very quickly.
Rx was stretching etc.
The only thing that might help is a footwear modification to reduce plantarflexion moments - a reverse grind off or SACH heel. Alternatively soft heel raises may help. 10mm poron or similar.

Good luck

Phil

 

Many thanks Philip for your useful advice.
Cheers
Sean

 

Sean

Where is the Geurdy's tubercle, I've never come across that name and a search reveals nothing - Ahh! I found it Gurdy's Tubercle = On the anterior aspect of the proximal tibia, the tibial tuberosity is the most prominent feature and is the attachment site of the patellar tendon. Approximately 2 to 3 cm lateral to the tibial tubercle is Gurdy's tubercle, which is the insertion site of the ilio-tibial band (ITB). Posterior to Gurdy's tubercle, the lateral condyle has a nearly circular facet on its postero-inferior surface for articulation with the head of the fibula.

http://thekneedoc.co.uk/content.asp?section=6&parentID=3&article=4

Dave Smith

 

The correct spelling is Gerdy's tubercle. Gerdy's tubercle is just superior-lateral to the tibial tuberosity and serves as the insertion point for the iliotibial band.

In addition, I don't understand why this athlete's complaints would be considered to be "neurological in origin", with the only positive neurological finding being a positive slump test. Why wouldn't the pain be considered to be simply mechanically-related tensile stress to the insertion point of the iliotibial band due to running with a more supinated foot with a tibial varum???

 

Dave,

many thanks for that useless sarcastic reply to my original posting. Like you I have made a spelling error!!! I would suggest that we both invest in medical dictionaries for Xmas.

Sean

 

Kevin, it used to be. I can still feel the emotions I used to feel twenty years ago waiting for the clinical staff to come and viva voce me about each patient. Back then we were expected to present the patient. These days I think it may be sadly lacking as Sean (or is it Paul) has demonstrated here.

Still waiting for that apology footsoldier

 

Gordon Bennet! Savage by name savage by nature :boxing: everyone's so touchy these days.

I really had not heard of Geurdy's, Gerdy's or Gurdy's tubercle and I thought you could tell me. I looked in a medical dictionary and online with no results. I was replying to you while at the same time I was Googling and trying diffrent spellings.
When it came up I thought it would be a good idea to carry on with the post for the sake of clarity, assuming I wasn't the only one to be unclear about Gerdys tubercle, i.e. in terms of where was the pain you were speaking of.


Stretch up, breath in aaannd relax, now everybody hug and think of the holidays comin up.(and beer) Sweeeeet!

Luv Dave

 

Sean

Now in reply to your OP (original post).

Are you describing an ITB Syndrome or insertion problem, which classicaly is made worse by increased runing especially with a heavy rucksack since this usually involves increased flexion of the knee, which allows it to internally rotate more and stretch the ITB. You have already noted that the ITB is tight and weak. Is it painful to palpate the area or can you ellicit local pain in any other way?

Since pronation causes internal rotation of the tibia this will aggravate the ITB syndrome or insertion. Adding heel lifts may improve the situation because since he is equinus in the ankle RoMs (and in the hamstings too), then a saggital plane progression block may result, which can lead to a compensations that increase pronation, which will then be reduced by raising the heel.

It seem entirely reasonable that he is tight in all the posterior muscles since he takes part in activities that make him exercise in a crouch position. This can lead to a false positive Lasègue's sign (SLR test), which has high sensitivity but low specificity. Does he get the pain if you raise the opposite leg, which I believe gives higher specificity.

He getting a little better - What makes you think its neurological?

I would concentrate on improving saggital plane progression e.g. FncHL? plus stretching and strengthening plus anti imflammatory procedures. Rocker type or toe spring shoes might help also especially if he has a hallux limitus or rigidus.

All the best Dave

 

Sean I notice you posted this patient is taking meds for a neurologic concern. Do you know what that concern is? He may have concomitant biomechanical foot issues but based on the limited information here I would suggest that is not his primary issue.

The discussion of his lateral leg pain at Gerdy's tubercle, weakness in the medial glutes and especially a + SLUMP would indicate to me the need to evaluate and rule out a more proximal complaint such as a midline disc (although a bilateral complaaint would be rare). Does he exhibit neurogenic intermittent claudication relieved by rest in a slumped posture? Weakness and cramping on exertion? Spinal stenosis is a valid differential.

 

Sean:

I wanted to publicly apologize to Sean for criticizing his style of patient presentation and using his patient case as an example. I have removed my remarks from my post from earlier today and will instead start another, new thread in the future on the subject of case presentations.

Sorry about that Sean.....you're obviously a good man and I appreciate your private comments.:drinks

 

Many thanks Dr Kirby for your apology. Looking forward to future discussions and contributions.
Thank you again,
Sean

 

Sean:

Sounds like case of iliotibial band syndrome to me, especially with his increased pain with running, his left greater than right tibial varum and if the tenderness is directly on the iliotibial band at the lateral femoral epicondyle or distally toward Gerdy's tubercle. I see nothing within your history to suggest this is neurological in origin, other than the positive slump test and that his GP is giving him medication for "neurological pain". Do you have a diagnosis for the neurological condition that his GP is medicating him for?

You say that his pain is worse at rest than with movement, but then say that his pain is worse after 10 minutes of running. If he were to run for an hour, would his pain still be worse at rest than with movement??

With the information you have given, and assuming this is not neurological in origin, and that it is likely iliotibial band syndrome, which commonly starts to get worse as running training mileage increases, I would think that heel lifts of 6 mm might be a good start, along with a forefoot valgus wedged orthosis, gluteal strengthening exercises and gastroc-soleus stretching exercises. It sounds like you have already done the heel lifts and forefoot valgus wedging. May be worth also trying extra the extra heel lifts to see what happens. You may want to also try increasing the varus support to the rearfoot and medial arch to see if this helps him. Also, when treating iliotibial band syndrome, I have the runners ice the knee for 20 minutes after running and for 10 minutes before they run in addition to trying to lightly stretch the IT band a couple of times per day.

Hope this helps.

 

Send patient to Neursurgeon or qualified Neurologist for testing, MRI and MRA. He needs to be evaluated as a patient for potential tendon lengthening procedures...