This case is going to be a 3-post series.  I would like to hear your feedback and comments.

A 29 year old male with main complaint of with L foot and distal shank numbness/heaviness.  It is also described as aggravating but not necessarily painful.  He describes the symptoms as fairly equal throughout and not necessarily in the shank, top of the foot or bottom but all “there”. It started when he got out of the car after a 2 hour trip about 12 weeks ago.  It comes and goes but hasn’t been bothersome enough until now to seek help due to the inconsistent nature.  He has no sleep disturbances due to this. It does get worse sometimes with current commute (1 hour to work) but just seems to be ‘there’ more often than not now.

One thing he really notices is that after he works out (such as running or even swimming), the same location feels more numb.  It would feel like he has cement on his shoe. It doesn’t bother him doing these activities (but has stopped lately due to it recreating the symptoms) and is quite strange that it would only come on afterwards.  It would go away however after a good 10-15 minutes.  It is starting to bother his work now if he is on his feet and walking around for a period of time.  This recently got worse and symptoms would increase from a 1/10 to a 5-6/10, to the point where he would need to sit back down or lie down.  He feels as if the symptoms are starting to arise in the contralateral limb too now.  Both of these factors are why he seeked assistance.

The patient denies low back pain or referral pain all the way down the leg.  It just seems to be “there” at the distal shank/foot (such as a glove/stocking pattern).  From a physical assessment standpoint, he has no pain to provocation to the lumbopelvic region and full ROM that is pain-free in all lumbar spine movements.  DTRs and light touch to palpation is intact but considering it feels ‘heavy’, the sensation may be less. Not really much of an improvement with repeated extension instanding and prone, even with overpressure laterall to the L5-S1 junction.  No pain in the hips and strength is strong and symmetrical bilaterally.

What do you think is going on? How would you approach examining this patient further and more importantly, treating this patient?

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7 comments

  1. Of course I would look at neurdynamics, However, a basic MDT tenet says if exercise does not worsen the Sx, but they are worse AFTER, then they may be fatigued and slouching more, contributing to a derangement syndrome.

  2. I would have probably done some neurodynamic testing to rule in or out nerve entrapment (tarsal tunnel syndrome) etc. Maybe look at tibial and sural nerve by biasing the foot.

    Looking forward to part 2!

    1. Thanks for commenting guys. Definitely are on the same track as I am (as you will see in post 2). I would like to get your feedback after that post comes out too.
      Hv

  3. Reminds me of a patient who had compartment syndrome, specifically in my case of the deep peroneal nerve. Also might look at a vascular stenosis although this may be pushing it. Differential diagnosis — working out / running worsening symptoms or provoking symptoms versus prolonged work on a stationary bike/recumbent bike in a flexed position- do symptoms change or are they the same.

    1. @ James and Jonathan,
      Thanks for the comments and definitely both assessments and diff Dx as I was thinking. Not to be short with comment, but don’t want to throw away what actually improved this patient. Come back next week! Thanks again guys.
      Hv

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