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Intermedial Dorsal Cutaneous Nerve Pathology

Discussion in 'Biomechanics, Sports and Foot orthoses' started by RobinP, Mar 23, 2012.

  1. RobinP

    RobinP Well-Known Member


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    Looking for some advice for something that is something I am struggling to devise a treatment plan for.

    Diagnosis of this 40 year old race walker is Intermedial Dorsal Cutaneous Nerve tension/compression.

    I have given advice regarding alteration of shoe lacing patterns to reduce compression and given some padding either side of the nerve pathway to ensure that there is no pressure on the nerve.

    However, the question I have is; are nerve glides appropriate and successful for intermedial dorsal cutaneous nerve tension.

    I am pretty sure that the compression is a factor but based on the fact that the patient experiences more problems walking downhill and the symptoms are relieved going uphill, I think that tension is the issue.

    I would appreciate any comments or if anyone can offer any other advice, I would be most grateful.

    Kind regards,

    Robin

    Just before anyone says anything, I have always thought it was the intermediate , not intermedial. Curiously, the Grays diagram says intermedial?! http://en.wikipedia.org/wiki/File:Gray836.png
     
  2. Mart

    Mart Well-Known Member

    how did you arrive at your dx ?

    regards

    Martin
     
  3. RobinP

    RobinP Well-Known Member

    SLR and slump accurately recreate symptoms. Percussion of the nerve on the dorsum of the foot also accurately replicates the symptoms.

    Eliminated all other possibilities than I can test clinically - don't have access the US or MRI

    Regards,

    Robin
     
  4. Mart

    Mart Well-Known Member

    what are patient's symptoms? any TMT or MTJ osteophytes present?

    Cheers Martin
     
  5. Robin:

    Race walking uses very exagerrated, long stride lengths which may, during contact phase, excessively plantarflex the ankle, especially going downhill. Even though I have never heard of the intermediate dorsal cutaneous nerve being injured in race walkers, it seems likely that excessive ankle plantarflexion motion is causing the issue.

    I would instruct the athlete to loosen all their shoe laces on the affected side and not race-walk downhill until the symptoms improve. Maybe he can stick to flat workouts for now or, if he needs to go downhill, have him slow down some to avoid excessive ankle plantarflexion. Topical Voltaren gel three times a day may also help.

    Hope that helps.
     
  6. drsha

    drsha Banned

    The intermediate dorsal cutaneous nerve is the peroneal nerve's terminal and lateral branch. The nerve supplies the foot dorsum laterally and to the 3-4-5 toes.
    Is that the isolated location of the patient's problem?

    Have you tried anesthetizing the IDCN, possibly prior to a racewalk, to see if all symptoms are eliminated or to expose a larger diagnostic dilemma?.

    Is there any numbness or other paresthetic symptomatology or only pain?
    I would think pure compression would produce some numbness in addition to pain in a racewalker.

    I would intensify my pontoon pads and incorporate them into the patients shoes so that they are always in place. Also, I would suggest a racewalking shoe with a higher throat.

    Biomechanically, if this patient has a flexible forefoot FFT, I would consider foot type-specific orthotics and compensatory threshold training of peroneus longus in order to increase medial column grf and reduce lateral column grf from causing tissue stress and excess movement within the shoe that may be participatory
    .
    If the patient has a rigid forefoot FFT than I would suggest that space occupation is the culprit and focus on that.

    Dennis
     
  7. RobinP

    RobinP Well-Known Member

    Hi Martin,

    There were no palpable osteophytes which is not to say that there weren't any so good suggestion

    Thanks

    Robin
     
  8. RobinP

    RobinP Well-Known Member

    Just an update on this patient, I spoke to her tonight and she used her trainers with the central lace loops skipped to reduce dorsal compression in addition to the padding I had added to create a relief channel and this allowed her to do a 20 mile walk with no problems.

    I have advised her tonight to try(as much as possible) to limit her downhill walking and if downhill is necessary, to shorten step length. She has been icing it as I suggested before and this also seems to be helping.

    Any opinions on ending to the physio for nerve glides?

    Thanks to all that have replied. Dennis, I'm sorry but I cannot follow your terminology so I am unable to really answer the questions

    Thanks

    Robin
     
  9. Robin:

    Personally, I have found physical therapy to not be helpful for these types of pathologies and, in fact, any manipulation of the nerve can exacerbate symptoms. Icing and avoiding compression and tension of the nerve should, over time, help with the symptoms.
     
  10. drsha

    drsha Banned

    No problem.
    I'm pleased your patient is doing well.

    Dennis
     
  11. RobinP

    RobinP Well-Known Member

    Ok many thanks for the advice. I shall update when I hear more.

    Regards

    Robin
     
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