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Bilateral leg pain
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Bilateral leg pain - August 18, 2006 11:20:00 AM
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yarringtonpt
Posts: 112
Joined: July 4, 2006
From: Waynesville, NC
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I had a patient referred to me today with a 2 month history of bilateral whole leg ache/pain. Pain was 0/10 before, during, and after eval. She had colon surgery for an infection 8 months ago. Prior to that she was on prednisone for asthma for 3 years. She had an "injection" for back pain months ago, and now she controls it with Advil.
Symptoms occur at night, waking her once per night - relieved with getting up and moving around. During the day, she gets leg pain with standing or walking greater thna 30 minutes; again, whole leg pain. The pain at night is the worst. Sitting in a recliner is the best position. Back pain is right sided but not consistent with leg pain.
On exam, she has relatively normal spinal AROM, negative SLR, prone knee bend positive for quad tightness, prone on elbows doesn't provoke pain. WNL neuro LE exam for sensation, strength, reflexes. I could not provoke her pain.
Frequent diarrhea from colon surgery: vit/mineal deficiency? - she cannot link pain to diet, activity (she gets leg pain at night regardless of ativity in the day).
Dx from physician, of course, bilateral knee/leg pain. She is having "leg x-rays" taken.
Peripheral pulses good, no trophic changes noted. Some minor tenderness along lumbar paraspinals. No significant LE flexibility issues.
She is very troubled by her decreasing mobility. I am at a loss except for spinal stenosis???
Any suggestions??
Thanks.
_____________________________
Eric Yarrington, PT, MPT, OCS
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Re: Bilateral leg pain - August 18, 2006 3:00:00 PM
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Tom Reeves DPT ATC
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To my knowledge there is no one nerve that services the entire LE. I would look refer to her doctor for a more comprehensive vascular evaluation.
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Re: Bilateral leg pain - August 19, 2006 2:29:00 AM
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emad/emad
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Tom ;
Why vascular ,eric reported no pulse change perphrial and no colour change i think ,am i correct ?I think you raise the vascular hypothesis because of night pain .
Any neuromuscular or nuropathic pain could be sleep-disturbant when it reaches high level .
I think we still needs more data ,such as work/job,sex,is the patient diabetic .
Reviewing the patient,s activities ,postions and what evokes pain ,sleep position all affect .
What physiotherapy have you applied.
Cheers
Emad
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Re: Bilateral leg pain - August 20, 2006 1:44:00 PM
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proud
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Eric,
That "injection" for back pain you mention in passing. I would like more info on that( type, why, date,etc).
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Re: Bilateral leg pain - August 20, 2006 2:11:00 PM
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rv36116
Posts: 216
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From: Texas
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I would perform a treadmill test to see when she gets her pain. Then perform a recumbent bike test to see if the pain comes at the same time. If it is the same time, then it's more than likely (if she has no Waddel's signs as a case PT will not help) vascular. Vascular because spinal positions of standing and sitting both produce the symptoms at the same time...
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Re: Bilateral leg pain - August 20, 2006 4:07:00 PM
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Karie
Posts: 107
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From: Wisconsin
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Check for visceral fascial restrictions or lymphatic congeston in the abdominal and pelvic girdle region. Postural positioning and endurance activities can have these affects if the above are problems. Abdominal surgery is noted for causing adhesions viscerally and depending where and how much can affect the spinal column through the fascial connections too.
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Re: Bilateral leg pain - August 20, 2006 4:38:00 PM
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proud
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Karie,
Dare I venture into this one. How is he going to check for that exactly?
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Re: Bilateral leg pain - August 20, 2006 4:49:00 PM
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Karie
Posts: 107
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From: Wisconsin
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Palpation methods for fascial restrictions. If not trained in palpating viscera or lymphatics then it would be a problem, maybe another clinician in his practice can check for him then.
Yes, this is real, I have surgeons refer to my practice for just this problem, visceral fascial restrictions etc.
It's okay to venture Proud, nothing ventured,nothing learned or gained....LOL
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Re: Bilateral leg pain - August 20, 2006 5:00:00 PM
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proud
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Okay, and I speak with little green men to guide my clinical practice...
To each their own.
Anywhooo... Eric, I think Rob PT has a good suggestion. Query neurogenic versus vascular claudication? We would have know patients age, and activity level.
Also, I am still interested in that "injection".
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Re: Bilateral leg pain - August 20, 2006 5:04:00 PM
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Karie
Posts: 107
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From: Wisconsin
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Another thought Eric, has the person been put on cholesterol lowering medication lately. Increased night pain and increased pain with exertion are classic examples of this problem as well.
Little green men would be cute, Leprechans are good luck I think.
Really Proud, I haven't practiced successfully for 25 years by being treating in a fantasy world. Personal attacks lower you credibility.
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Re: Bilateral leg pain - August 20, 2006 5:20:00 PM
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proud
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My apologies karie, an attempt at humour. I get carried away at times.
You have to admit, the concept is a little "outer edge". That is all I was saying. It just does not fit into what I consider my scope of practice. And I think my opinion on EBP is well documented here on rehabedge.
I will end it at that.
take care.
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Re: Bilateral leg pain - August 20, 2006 5:49:00 PM
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Karie
Posts: 107
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From: Wisconsin
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Thanks proud for the apology.
I drove the instructors of some of these areas nuts when I started taking them, thinking it was all out there too....long story why I even was there, but I can't discount the leap of improvement in my patients with these techniques and I see alot of the people that everyone else has given up on for one reason or another. It's important to keep the EBM in mind, and I really appreciate learning how you and others are using it, but I can never go back to being "in the box" and working with fascia is not out of our scope of practice, nor is the lymphatics. I enjoy dialoguing with you Proud, you are obviously very bright and learned in what you know. I guess I am not into scarasm type humor, our world is filled with alot of negativity and I try not to add to it.
I will let the rest of you assist Eric, but if he doesn't get anywhere with all of your suggestions, which I am sure are sound and possible answers, these are just other avenues he can give his patient. Post surgical fascial issues can accumulate into many issues and result in total disruption of a person's life on many levels.
For example, if there is problems with absorbition in the intestines etc. since the surgical procedures, nutrient deficiency may become a problem. Some people develop problems with grains after surgery and this affects many organ and musculoskeletal systems. If you check the nutrition research, whole grain diets are found to reduce inflammation. You see Proud, I just look at a bigger picture that affects what we do in our scope of practice, that's my path, not yours and that's okay. No path is invalid just different and successful in it's own right.
Good luck Eric!
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Re: Bilateral leg pain - August 21, 2006 4:10:00 AM
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yarringtonpt
Posts: 112
Joined: July 4, 2006
From: Waynesville, NC
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Everyone:
Thanks for all of the comments/advice. I apologize for having not been able to get to a computer this weekend. I'll try to respond to everyone in order of posts.
Tom: I understand that there is no one nerve that innervates the entire LE. I had considered vascular, but like emad stated, nothing on my exam leads me that way.
emad: White female, age 73, non-diabetic, fairly inactive since colon infection/surgery in December, goes to church every morning and sings in choir on Sunday. No treatments yet, just evaluation. Aggravating factors are standing >30min, walking >45min, bending/stooping, and stairs.
proud: she was vague on the injections (2 years ago for hip and back pain, and in March 2006. The MD that does it typically does facet or selective nerve root blocks, so with the risk of assuming, I'd say one of the two with a combo corticosteroid and anesthetic??
Rob: I was planning on treadmill and recumbant bike at next visit - we'll se how it goes.
Karie: I am not really trained in visceral mobs and I'd have to fake my way thorugh it. I have gone to and do use strain and counterstrain - she has a bunch of hot anterior thoracic, lumbar and pelvic tender points (proud - consider the can of worms opened) - so I plan on treatin them. I'm sure with the exent of her infections and colon surgery, she has fascial restrictions.
Thanks all,
Eic
_____________________________
Eric Yarrington, PT, MPT, OCS
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Re: Bilateral leg pain - August 21, 2006 7:57:00 AM
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Shill
Posts: 1096
Joined: February 13, 2003
From: Madison WI USA
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Eric,
You mentioned that prone on elbows didnt provoke pain.
My follow up (actually, it would be my focal point, not a follow up) on this would be to take her through a through, mechanical spine evaluation, complete with repeated movement evaluation. Just because she is 73, dont rule out that extension may relieve symptoms. Go through a McKenzie (more widely known), or the similar Strategic Orthopedics (more detailed, and in my opinion better) type of evaluation, looking for centralization.
We could argue at length why she might get relief with repeated movements, but lets not.
As Rob suggested, the bicycle test can help you determine whether there is a supply versus demand vascular issue.
Let us know what you do, and how she does.
Thanks,
Steve
_____________________________
Steve Hill PT
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Re: Bilateral leg pain - August 21, 2006 9:09:00 AM
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Alex Brenner PT MPT OCS
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From: Kentucky
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I agree that neuro versus vascular claudication should be examined further.
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Alex Brenner, PT, MPT, OCS
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Re: Bilateral leg pain - August 22, 2006 6:06:00 PM
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jboypt
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Joined: August 17, 2006
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Rob,
How come your suggesting stenosis testing? Eric placed this pt. prone on elbows without provoking symptoms. Central canal stenosis or lateral canal stenosis would have caused symptoms with prone on elbows IMMEDIATELY. Stenosis does not change......... ever. Extension (loaded or unloaded) will always produce at least LE and possibly back symptoms immediately. Flexion movements will always relieve or abolish symptoms. This pt. reports changing symptoms. Shill AKA Steve has got the right idea.
John
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Re: Bilateral leg pain - August 22, 2006 11:09:00 PM
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rv36116
Posts: 216
Joined: August 5, 2006
From: Texas
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Just browsed through the post and caught the discussion part of the vascular vs. stenosis...
Reading the whole topic from beggining to end would probably be the most logical thing in the future probably...
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Re: Bilateral leg pain - August 23, 2006 2:55:00 AM
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proud
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John Miller,
I was taught on a "D" course that prone on elbows may not always expose stenosis? It may require more provacation in a small percentage?
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Re: Bilateral leg pain - August 23, 2006 5:33:00 PM
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jboypt
Posts: 16
Joined: August 17, 2006
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Proud,
You may be correct. Prone on elbows is mid range extension and theoretically you may have to take someone to end range to produce symptoms. However, what do you think the chances of having to do that with someone that reports LE sypmtoms with walking? In another words, if a pt. reports LE symtoms with walking, that amount of extension in the lumbar spine is no where close to their full end range extension. I have never seen a true stenotic pt. that performed prone on elbows or extension in standing didn't produce their LE symptoms. These people don't extend more than walking because they know that makes them worse. Since you admitted you took a part D course I'll share my opion regarding evaluation of this pt. I would go back to the subjective and try to determine if this pt. ever obstructs to movement (does she lose motion when she is symptomatic and have full motion when asymptomatic) this would clue in a derangement. She can't have a dysfunction or an entrapment based on what Eric posted (entrapment symptoms are constant and dysfunctions don't refer to the leg). ANR, derangement, and mechanically inconclusive are the only mechanical possibilities with the current information posted.
John
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Re: Bilateral leg pain - August 23, 2006 6:04:00 PM
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proud
Posts: 944
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Thanks John,
I also think more information is required to move us forward on the dx.
Regards
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