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I thought I would throw this one out to see if anyone can come up with some better ideas than I’ve managed so far!

We have a 56year old male tennis coach who has been attending our multidisciplinary clinic since June 09. He has no previous medical history of note and no previous operations.

In June 09 he saw the Myotherapist after seeing a Pod at another practice for LF plantarfasciitis and Morton’s neuroma pain for which the pt was given some orthotics. The pt found an increase in neural pain with these orthotics in the feet and tightness into the calf. He had also had 10 days of Left Sacroiliac joint pain. Myotherapist referred onto the Physio who diagnosed lumbar pelvic dysfunction causing L5/T1 nerve root irritation. Physiotherapy treatment reduced the neural symptoms and pain. Pt was pain free for a month, then ran for a bus and went out dancing for a night; the pain then returned.

I reviewed the pt in August 09 clinical signs positive for plantarfaciitis but –ve for Morton’s neuroma. He also presented with cavoid foot type with gastrocs equinus, FF varus and plantarflexed 1st ray. During gait cycle pt is supinated throughout. Issued pt with new orthotics, neutral shell with lateral heel skive, 1st ray cut out, FF extension and plantarfascia groove. Pain relief obtained with orthotics and continued physio/Myotherapy for release of gluetals, piriformis and femoral heads.

Jan ’10 – pins and needles back in both feet after a particularly busy weekend teaching. Seen by Physio, T12-L1 mobilisation reproduced symptoms. Pain present at rest and especially at night. Sent by GP to see Orthopod. MRI showed no nerve root compression. Sent by Orthpod to see Neurologist who suspects tarsal tunnel syndrome. Plan is to do nerve conduction test. However, he has a negative to Tinel’s sign. Patient can reproduce symptoms by, as he says “grabbing my hamstrings just above the knee causes the pain to come on straight away.”

My question is if not tarsal tunnel syndrome then what? I did think compartment issues but they would not reproduce this type of pain. Could it be a nerve entrapment around the knee area? Any ideas?

Thanks for reading.

Alex

 

http://emedicine.medscape.com/article/1234809-overview

 

Hi:
Well, there are a lot of nerve entrapements, radiculopathies, neuropathies that affect the foot, not just Tarsal Tunnel Syndrome.

A Tarsal Tunnel syndrome will CLASSICALLY exhibit symptoms attributed to the innervation of the posterior tibial nerve and it's branches (some, all or a combination)

It sounds as though your patient's etiology is more proximal.

Steve

 

"T12-L1 mobilisation reproduced symptoms. "
Clients occupation requires bend and twist at T12-L1.
Enervation of Psoas minor and attachment in this area would be affected.
Failure of psoas minor results in lack of support of anterior pelvis. Substitution for psoas minor is commonly the hamstrings which pull down the posterior pelvis to make up for lift of anterior pelvis. This matches the client report of grabbing hamstrings and setting off symptoms.
The foot reflex for T12-L1 is at the proxemel end of the first metatarsal. If the psoas minor tonicity is uneven giving anterior tilt on one side and posterior tilt to the other the response is to raise the arch on one side and lower it on the other to compensate.
This has become my specialty because I suffer from it myself. I have the greatest relief by wearing a back brace with a 3 inch x1/4 inch magnet at T12-L1.
Hans Albert Quistorff, LMP
Antalgic Posture Pain Specialist