A few weeks ago I posted an initial blog entitled, L LE Symptoms: What do you think? Part 1. I want to first thank Jesse Awenus from jessephysio, Erson Religioso from themanualtherapist, and Kyle Ridgeway from PT Think Tank for their comments and suggestions; as well anyone else who read it and contemplated in their minds what to do.
In short, I did not get the response that I normally would get with this type of case (reason I am posting it). Here are some of the treatments that I performed.
1. Neurodynamics in supine concentrating on the sciatic nerve, as well as sural and saphenous components with no change in symptoms (even tried femoral nerve in prone but no change either).
2. Manipulation to the thoracic spine (concentrating on T4-10), and the lumbar spine and SIJ (in lateral recumbent positions). Some relief, but mainly a small dampening of the effect (again, not what you would want to call centralization); just dampening to a small degree.
3. Repeated movements with and without practitioner overpressure. As I stated in the initial post, this patient did not complain of focal symptoms (and none to palpation over major structures in prone, standing and supine). The patient also had full-pain, free ROM. Repeated extension in prone (prone press-ups) in neutral, with the hips shifted to the left (first try and then no change), so tried with hips shifted to the right (no change). Clinician overpressure locally at L5-S1 and L4-5 hitting end-range (pt could pretty much get to end range on his own though) such as a rotational mobilization with overpressure maybe dampened the symptoms too (pretty much the same effect as manipulation).
4. General exercise including bent knee rotations, stretching of the hamstrings/piriformis, hip flexors and bridges had no direct effect, possibly psychological that he could move and this did not make symptoms worse or better.
As of now, a dampening effect occurred but no centralization and no real directional preference of certainty. Symptoms were not necessarily getting worse, but no better (not much improvement over 3 months). I was contemplating referring to medical physician for possible prednisone series to see if it will calm down a chemical mediator, as this was not acting as mechanical as I would want.
Where would you go next? Have any other ideas?