A couple of months ago, a lady came into our chiropractic clinic complaining of recurrent sharp pain in the foot with numbness and cramps in the leg. Classic symptoms of chronic neurological conditions, I thought to myself.
The client already had a nerve conduction study done and the findings suggested nerve pathology.
The patient decided to seek chiropractic treatment while waiting for her specialist appointment.
To give a bit of context, this lady patient is a homemaker in her 50s. She also experienced loss of dorsiflexion (i.e. unable to point her toes upwards), numbness in one leg, as well as leg cramps.
Today, we want to share with your our work process.
Neurological symptoms: numbness and tingling, cramps
Before we move on, it is important for you to understand what are neurological symptoms and the common neurological disorders these symptoms are often associated with.
Neurology refers to the branch of medicine that deals with the nervous system. This include both the central nervous system (brain and spinal cord) as well as the peripheral nervous system (nerves from the moment they out come of your spine).
Neurological symptoms can be unique and usually suggests an involvement of the nervous system. Some of the common neurological symptoms in musculoskeletal conditions are: numbness and tingling, electric shock sensation, weakness.
Neurological disorders are usually used in the context of diseases such as Parkinson’s disease, dementia, or epilepsy. However, there are conditions that are more “benign” in nature that have a neurological component. This include: disc herniations, sciatica, carpel tunnel syndrome or thoracic outlet syndrome.
Causes of numbness and tingling
Common peroneal (fibular) nerve or superficial peroneal nerve
When it comes to numbness and tingling, we think of nervous tissue involved. The most obvious place to start would be where the patient experiences the symptoms.
The outside (lateral aspect) of your leg is predominantly innervated by two nerves – the common peroneal nerve for the upper third and the superficial peroneal nerve for the lower two thirds of the leg.
Remember, the patient did test positive in her nerve conduction study.
p.s. it is important to note at this stage that both the deep peroneal nerve (we’ll talk about this later) and the superficial peroneal nerve are branches from the common peroneal nerve.
Slipped disc, lumbar disc herniation – L5 or S1 nerve roots
If we are thinking nerve root involvement (i.e. slipped disc), we would be thinking L5 or S1. This is also the areas that will coincide where the client experiences numbness and tingling.
The most common site of lumbar disc herniation occurs indeed at the L4/L5 level (which affects the L4 nerve roots) and L5/S1 (which affects the L5 nerve roots).
It is common for people to panic when they received a slipped disc diagnosis. The good news is you don’t have much to worry about most of the time. As mentioned in our earlier blog posts on lower back pain treatment and MRI vs. slipped disc, most disc herniations resorb by themselves without intervention.
Vitamin B 12 deficiency
Vitamin B12 is one of the essential vitamins for your body.
Essential vitamins refers to vitamins that your body cannot manufacture on its own. Therefore, your body relies sole on your dietary consumption of vitamin B12 to function. The good news is that vitamin B12 is found naturally in most animal products from poultry, to meat, to fish, and even diary products.
Unfortunately, it is not usually naturally found in plant-based foods.
Vitamin B 12 deficiency doesn’t affect most of us. Individuals who are anaemic, vegan, or vegetarian are at higher risk of developing it.
Diabetes is a metabolic disease where there is an impairment in the body’s ability to process glucose.
Causes for loss of dorsiflexion
Deep peroneal (fibular) nerve
The nerves that allows you to point your foot up is different from the ones that allow you to feel sensations on the skin. The nerve responsible for dorsiflexion is your deep peroneal (fibular) nerve.
It is often the culprit for foot drop or loss of dorsiflexion.
Peroneal neuropathy refers to pathology of the peroneal nerve or specficially the common peroneal nerve. While the common peroneal nerve itself doesn’t provide motor function to the foot, the deep peroneal nerve (which branches off the common peroneal nerve) does.
It is important to understand this the cause of foot drop in patients is often attributed to peroneal neuropathy. The other symptoms include sensory loss (numbness) to the front and outside of the leg plus the top surface of the foot.
Slipped disc, lumbar disc herniation – L5 nerve roots
When it comes to motor function, we think of myotomes. The L5 nerve roots (L4 to S1 to be precise) supply the nerves to the muscles that raises the foot and the big toe.
However, the L5 nerve root is the most commonly affected.
Reference: Foot Drop in BMJ, 2015
Causes for cramps
Earlier we mentioned peroneal neuropathy where the peroneal nerve is affected. In cases of polyneuropathy, multiple nerves are affected. Examples of polyneuropathy includes diabetic neuropathy where multiple nerves are affected. Cramping is a symptom that is often associated with polyneuropathy.
It is common for pregnant women to experience cramps – similar to period cramps – in their first trimester. This is normal. The cramping can be due to the implantation process – where the embryo attaches itself to the uterine wall or from the uterine growth as a response to the developing fetus.
Hypothyroidism occurs when the thyroid hormone levels in your body fall below normal limits. Common symptoms are fatigue, weight gain, depression, and also muscle cramping.
Diagnosis can be done via blood test. If you suffer from hypothyroidism, you can easily address this condition with medication
Fluid or electrolyte disorder
Fluid or electrolyte disorders can occur from seemingly benign circumstances such as dehydration or poor nutrition to complex issues such as kidney failure.
Most of us are familiar with isotonic drinks such as 100 Plus or H-Two-O. These sports drinks are designed to replenish your electrolytes (and glucose) levels after sports to facilitate recovery. You may also see athlete eating bananas before or after sports. This is because banana is a rich source of potassium and magnesium.
Square One’s approach to managing neurological symptoms
In cases such as this patient, we advise that conservative care may improve the patient’s function and symptoms. However, it is possible that the client will not achieve full resolution of her symptoms.
Please note that this patient was already managed under standard medical care and was awaiting her appointment for an orthopedist (do not ask me why she was referred to one in the first place) and subsequently a neurologist. She was not referred for physiotherapy treatment (do not ask me why either).
Our treatment for loss of ankle range of motion
Because the waiting period for a specialist appointment is about three months, we decided to work on the most obvious issue first – the loss of ankle dorsiflexion.
We chose to take a holistic functional approach to this client’s care by working with both the foot and the ankle. The exercises we prescribed at the first visit are:
Exercise 1 +2: towel toe curls and toe isolation
No different from the exercises Kingsley did as part of his Achilles tendon/ankle sprain rehabilitation program.
What was interesting was that the patient experienced remarkably intense pain while performing the exercise. The patient also didn’t have good control of her toes – e.g. she couldn’t raise her big toe independent of the other four toe and vice versa.
Because of that, we prescribed her with an exercises to help her train herself to lift her big toe independent from her other toes and to lift the four toes independent of big toes.
We also advised the client to work with the towel toe curl exercise WITHIN her pain limits and preferably <5/10 in pain score. This will allow the patient to slowly work through the exercises without causing too much aggravation.
Exercise 3: heel raises
Because the patient could not dorsiflex (point the ankle upwards), it makes sense for her to do some strengthen work. We prescribed her with some standing heel raises to get her started with ankle strengthening.
Exercise 4 + 5: box squats and one leg step up
Again, we decided to take a holistic approach to this client’s management. Instead of just working on the symptoms alone, we also wanted to increase her function.
She is active and does low impact exercises such as walking. Because she doesn’t do other types of exercises or training, she couldn’t get into a squat position with ease and also struggle one with one leg sit-to-stand.
These two exercises are aimed to increase her lower limb function.
Clinical rationale for the prescribed rehab exercises
The truth is that in complex cases, we do not know for certain how the patient will respond.
The prescribed exercises aimed at addressing the loss of dorsiflexion was to test if the cause is muscular in nature. If the loss is muscular in nature (i,e. strength loss as a result of disuse), we can expect her ankle range of motion/strength to improve after this workout series.
We also decided to keep the towel toe curl exercise despite of the pain because we wanted to see how graded exposure would change her pain experience. We believed that she had sufficient self-efficacy to work through the exercise.
Lastly, we wanted to improve her general lower limb function to help with her self-efficacy – if the other prescribed exercises did not work, we wanted her to at least be able to squat better.
Progress update #1
After doing the exercises for two weeks, the patient reported she could
- Towel toe curl without pain
- Sit-to-stand AND one leg step up with minimal effort
- Heel raise with minimal effort
For us this is a big win! Much to the client’s surprise (and our own surprise), her foot pain completely resolved by just two weeks of the prescribed exercises.
The numbness and tingling improved with the exercises (but only provided temporary relief of less than 30 minutes) and her ankle dorsiflexion remained the same.
Given the nature of her complaints, we think this is a good start.
As mentioned earlier, we did advise the client that she may not experience full resolution of the symptoms.
The fact that she could improve her symptoms with only two weeks of exercises is a good indicator that she may continue to experience more improvement in the long run.
Developing self-efficacy is a part of the treatment
Again, self-efficacy is important to us.
To demonstrate to the client that she is stronger and more able than she think, we worked on box jumps on the second visit.
We do have a soft plyometric box at our chiropractic clinic.
Because the client did not have enough confidence to commit to a full jump, she struggled for the first two or three attempts.
Instead of getting to try further or harder with words of encouragement, we decided to confront her fear of falling first. To do this, we get her to jump on the box landing on her shins. (Remember, we have a soft plyometric box.) We wanted to demonstrate it is okay to commit to a box jump and it is also okay to fail because it doesn’t hurt.
So we got her to try probably another two to three intentionally “failed” box jumps and with each jump, we encouraged her to get further onto the box (i.e. more of the shin cleared the edge of the box).
Once she managed to cleared over half, we got her to try a box jump again and she got on!
We asked her if she would like to try again. She immediately agreed with much enthusiasm and went straight for it!
p.s. This part of the treatment program is solely to increase self-efficacy. We did not ask her to continue with more box jumps and jumping was also not prescribed as part of her home exercise program. We just needed her to see that she can – rather than just taking our word for it – and she did achieve just that.
After thoughts from a chiropractor’s perspective
We believe in a biopsychosocial approach to treating musculoskeletal conditions. This means we don’t just work with your symptoms or presenting complaint, we also work with the pertinent functional impairments that we may observe.
Going beyond what traditional chiropractors or physiotherapists would do, we also address self-efficacy.
Because we truly believe in empowerment. We believe in making each and every of our client empowered to manage their own condition and symptoms. We believe this is the only true way to achieve full recovery and long term results.
Ten takeaway lessons
From a patient or client perspective, your case may seem simple.
“I have low back. Fix it.”
“I have numbness and tingling. Fix it.”
Unfortunately the unspoken and often un-observable clinical process is a lot more complicated than what it would seem.
Here are the take away lessons:
- Most musculoskeletal conditions are complicated and multifactorial in nature
- It is often impossible to find one-cause, one-cure that most of us would like
- Neurological symptoms may be due to other conditions – diabetes, hypothyroidism
- Exercise prescription is not a matter of doing the same thing all the time for every person
- The considerations we have for your full recovery also include whether you are confident enough to achieve full recovery
- Quite often there are other issues that run concurrently to your primary complaint (e.g. unable to squat confidently, thinking you are weak when you are not)
- It is okay to do exercises that cause a lot of pain – we just need to manage the exercise well to get optimal results
- Few chiropractors or physiotherapists will admit this: we don’t always know if an exercise would not or would not work without you trying
- Treatments for neurological disorders can include exercise and can also be rewarding for you
- Even in cases where you are tested positive for certain pathology, you can still get some improvements with the right treatment (e.g. improve your ankle movement by 50%, reduce your pain score to zero)
- You are stronger than you think
- It is okay to fail because failure in itself often has value if you allow yourself to find it
In part two, we will discuss the numbness and tingling the client is experiencing and how we helped her as part of chiropractic care.
Are you currently seeking help for your numbness and tingling? If you are not getting the results you are after, reach out to us. We will be happy to discuss your case and advise on if we would do it differently.
Remember, always seek professional help. Evidence-based chiropractors or physiotherapists preferred.