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Adverse neural tension

Discussion in 'Biomechanics, Sports and Foot orthoses' started by LMadeley, May 22, 2008.

  1. LMadeley

    LMadeley Member

    Members do not see these Ads. Sign Up.
    Just interested in thoughts on a particular case I recently experienced.

    A middle-age women experienced numbness of 4th and 5th digits of the left foot only (2 weeks in duration). The patient has a history of type 2 DM of 4 years that is well controlled. The onset of numbness coincided with an interstate flight of around 1 hour in duration. GP precribed aspirin.

    O/E: The patient lacked soft touch (protective sensation of all sites of both feet were intact) around 4th and 5th digits. Pain/ allodynia (not paraesthesia) was reproduced with the slump test as the foot was everted. Tinels sign was also evident on percussion of the dorsal cutaneous nerve. Additionally, tinels sign was evident on percussion of the of the dorsal intermediate cutaneous nerve (branch of the superficial peroneal nerve as it passes through the inferior extensor retinaculum).

    A preliminary diagnosis of adverse neural tension of the common peroneal nerve and its branches was made. I advised gastroc-soleal, peroneal and hamstring stretches.

    Any extra thoughts?
  2. Adrian Misseri

    Adrian Misseri Active Member

    To confirm diagnosis, pop a bit of LA around the dorsal cutaneous nerve (saphenous nerve). If symptoms resolve, you can confirm diagnosis.

  3. LMadeley

    LMadeley Member

    Saphenous nerve supplies cutaneous innervation to MLA??
  4. Adrian Misseri

    Adrian Misseri Active Member

    Yes your right.. my mistake.. constantly mixing up sural and saphenopus nerves (names not locations). Should be sural nerve. Have been thinking might be worth doing same for superficial peroneal nerve as well if sural nerve doesn't respond. Anatomical variaotion can give either control of cutaneous structures of 4th and 5th, either dorsal or plantar. Good link to see how to do it.

    http://www.latrobe.edu.au/podiatry/LAvideos/Ankle & regional LA.pdf
  5. pgcarter

    pgcarter Well-Known Member

    Hi Luke,
    Adverse neural tension is dealt with by some physios better then others....it is a problem I have had for many years ....getting worse as I get older and more arthritic and less active. For me slump stretching (which I need to do pretty gently, 10 seconds three times and I'm dizzy for a while afterwards) and plenty of posterior compartment stretching of legs, varying the degree of inversion/pronation at the STJ while I stretch seems to help.
    Phill Carter
  6. Intermediate dorsal cutaneuos traumatic neuritis could be caused by excessive pressure or a direct blow to that nerve about the ankle. This pressure could have been caused by a tight sock by, for example, increased ankle swelling during the flight from the superior border of a short tight sock or the lady crossing her leg onto the nerve during the flight, or striking her ankle on a hard object (i.e. carrying luggage). If there is a Tinel's sign, this generally indicates some form of nerve injury at the location of the Tinel's sign, not "adverse neural tension". Tell her the symptoms should go away in 3-12 months and to avoid tight clothing/shoes in the area while it is healing to reduce any discomfort. Aspirin and nonsteroidal anti-inflammatories may also give her some symptomatic relief.

    By the way, the intermediate dorsal cutaneous nerve is easily palpable and visualized in most thin individuals at the ankle joint level if the foot is plantarflexed and inverted maximally. It will look like a tight cord under the skin in the plantarflexed-inverted position. I doubt your patient is thin enough to demonstrate this effect clinically.
  7. Ann PT

    Ann PT Active Member

    Given its course around the lateral ankle, wouldn't eversion of the foot take tension OFF the dorsal cutaneous nerve? And if the problem was nerve tension, I would recommend nerve gliding techniques as opposed to stretching. In my experience, "stretching" a nerve, be it adhered or inflamed, generally increases the patient's symptoms.

  8. MelbPod

    MelbPod Active Member

    Interested in learning more of Adverse Neural Tension and any diagnostic tests (other than slump and Tinels?)

    I had a guy in today (30ish) indian origin.
    Fit and healthy
    Training for 10km run, also does drama (lots of jumping around)
    Symptoms began after trip to Thailand 12 months ago. (originally thought massage may have been cause)

    - Neural pain and sensations at 1st webspace on Right. Pains radiate into Hallux.
    - Same pain also present at anterior ankle and at times across dorsum (in line with deep peroneal nerve)
    - In Questioning, pain also at fibula head and lower back (intermittent)

    -tibial varum
    - FF supinatus (only on Right)

    I began Questioning Neural tension but not sure if it fits the picture?

    What you reckon?
  9. pgcarter

    pgcarter Well-Known Member

    I don't know enough about it to help you, I've really only got the terminology used by the physio who treated me and introduced me to the ideas....so whatever you call it she showed me a slump position in order to "stretch" or help my problem ...and I get burning at low back, knee\peroneal area and sometimes into feet through heels and up to 2 nd met head....and stretching and slumping and working my feet through a range of positions of inversion and eversion and dorsiflexion seems to help the outcome and decrease sensitivity, increase comfort and mobility over a day.
  10. Griff

    Griff Moderator

    Given the onset you describe it seems like a neuropraxia/neural sensitisation issue. I agree with Ann, a slump test (or straight leg raise test) with the foot in eversion would not normally bias the sural nerve - maybe it was more a tibial nerve (lateral branch) test? Was the foot in a plantarflexed/dorsiflexed position also?

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