Heel pain and neural tension?

I am confused by a patient I saw today who complains of sharp, I/T (L) heel pain ( posterior-medial on palpation)when sit for >½ hour, it eases immediately when she stands up and walks or if she stretches her calf muscles. She has had this pain the last 2 weeks, after being treated for left knee pain (bad OA and patella femoral pain, worsened after fall 2/12 ago) and LBP (LBP started 1 month ago, but has longstanding back pain and stress #'s (not seen xray yet and patient didn't know where) and reports having Osteoporosis. She states that when heel pain gets bad, her LBP starts.

I initially thought lumbar referred pain due to aggravating behavior, but when tested Lx AM's I only reproduced LBP. (Could not do OP's due to fear of stressing spine too much)

When i did SLR LBP was reproduced very early in range ( 15 deg) bilaterally and DECREASED with passive dorsiflexion (???)
No heel pain was reproduced.
I found stiffness in her subtalar joint, and when i distracted her Calcaneous on Talus her pain was abolished (from 5/10).

I am confused about her neural tension result, and why dorsiflexion also reduces her heel pain.

I would like to perform a neuro examination on her next visit and also do a gentle PAIVM examination of her lx spine to just clear any chance of referred pain.

What's her diagnosis?
I am currently thinking that her stiff subtalar joint is causing the plantar fascia pain, and by mobilising the joint we can reduce the compression from tight gastrocks/soleus and plantar fascia- but shouldn't the pain increase when she does active dorsiflexion?

Any comments to this??

Regards

confused PT

[somasimple]

Hi Keen,

Do not be confused there. The results are quite normal for those who use neurodynamics’ stuff.
You have done a neural mobilization (gentle stretching of nerves/neural tissues) and pain was normally reduced.
A LBP may produce side effects at distance and you’re not confused with a sciatica case which is quite similar and you know that a sciatica may produce foot problems!

So are you saying it's likely to be a Lx referred problem even though no heel pain was brought on by stressing the lumbar spine, or are you suggesting it's the sciatic nerve which has adverse neural tension? and why the improvement with added dorsiflexion in SLR position?

Regards

Keen PT

[somasimple]

Hi Keen,

You said that a SLR was painful. A SLR test is a neural test which often/ever produces a tension over the sciatic nerve. But a nerve is a physical entity which has limited elastic properties.
But if you stretch lightly the sciatic nerve, you give a bit ROM to the nerve and reduce immediately pain. It is why you got quick improvement with dorsi-flexion.

Here is an visual explanation with a flash animation.
<a href="http://www.somasimple.com/flash_anims/nerves_ropes_02.swf" target="_new">http://www.somasimple.com/flash_anims/nerves_ropes_02.swf</a>

So, you may have no pain at heel when provoking lumbar spine but pain when doing a SLR where sciatic nerve is already near its limits.

Bernard, PT

[Physiobase]

If the pain is neural in origin you might look for the restriction more peripherally, in the popliteal region where thing branch in to tibial and peroneal nerves. Also the common peroneal nerve exit at the distal third of the tibia etc. If she also had knee pain and the heal pain arose following that I should think it is worth investigating this area.

Note on LLTT's the difference between adding in dorsiflexion before SLR and adding it in pre SLR. This might give a clearer direction as to where any possible restriction might be.

I would never forget to also mobilize the head of the fibular as a possible source and remedy to referred knee pain and other symptoms that don't quite add up 8o

as almost all non traumatic musculoskeletal pain is a referred problem I cannot understand your confusion, it is quite clearly a referred pain phenomenon. Mobilise L5 thoroughly and observe the changes to this pain problem. It is by no means necessary in the diagnosis of a referred pain event to reproduce the pain with active and or passive movements of any relevant structure. It is a bonus if you can observe the connections prior to treatment. Simply apply mobilisation to L5 /s1 thoroughly, this may take four or five minutes , . Dural stretches of the sciatic trunk will be of value also.
The give away signs are the back pain that occurrs at the time or around the time of increased heel pain. It is more the case of attempting to prove that these common problems are not referred than to do the reverse.
Cheers
Geoff

[somasimple]

Hi,

Mobilise L5 thoroughly and observe the changes to this pain problem

I'm a bit confused there! How can I mobilize L5 without touching any other joint?

with your thumb.

[somasimple]

Geoff,
All my friends are saying that I have a wide open mind. All are saying too that I'm stubborn but logical and my arguments are scientifically based.

But logically, if I have a chance to mobilize a facet joint located 8 cm deep with my thumb without mobilizing skin and muscles... BTW, facet joints are twins and applied on another vertebrae...

Some papers show that trying to realize a such job is not really possible?

dear somasimple, mobilisation and the effects of joint dysfunction etc are well covered in the orthopaedic literature, if you are able to access a good physiotherapy library you may want to read something by Geoffrey Maitland. He is a well acknowledged father if you like of the business of facet joint function and movement therapies. His work however falls short of the full picture in some important ways. I will elaborate when I have more time , for now it may be as well to consider the detail of my piece posted earlier, "the physiology of spinal pain, a theoretical model". I will attempt to outline the mobilisation process as best I can in my next post.
Cheers

[somasimple]

Dear Geoff,

You're certainly joking, there!
Maitland is certainly one of founders of osteopathy but none therapy had shown a superiority on another.
Osteopathy as PT and ... works on some, fails on others. :\

On the contrary, there would be tons of evidence showing its superiority! |I

But anatomically (and I do not need a book for this basic knowledge), a vertebrae has 4 facets joints.
2 on each side and it is a fact that in the lumbar area the vertebral body is situated at a depth 8/10 cm. I can say it because I saw it in surgery rooms and in my manuals.

So, trying to mobilize a (and only one) facet joint in these conditions is simply non logical, non anatomical, non scientific and an absolute impossibility!:rollin

dear somasimple,
Geoffrey Maitland was an Adelaide , south Australian trained physiotherapist, I'm not sure he would wish to be identified as an Osteopathic guru. His foundation of a lifetime of work and writing on the science of facet joint function and treatments formed the basis for many others who followed. Including my own work. It does appear from your writing that you have not been exposed to manual facet joint mobilisation. What an exciting place for you to be . There is much to discover and I hope I am able to help you in some way.
Would be so much better of course if you could attend one of my lectures or sit in on a tutorial, nevertheless I'll do my best to assist.
I'll be able to sit long enough at the computer to attend to a brief overview etc tomorrow.
Cheers
Geoff
While I may add the occasional comic relief , I assure you , I am not joking.

[somasimple]

dear Geoff,

So, trying to mobilize a (and only one) facet joint in these conditions is simply non logical, non anatomical, non scientific and an absolute impossibility!

Just try to bring some arguments which may invalidate my quote!

I'm certainly not a serious man but I'm doing seriously my job and I'm not selling my knowledge but simply sharing it!

[Physiobase]

Well done guys, keep it light & debatable but friendly. That's what this forum is all about, whilst remembering that many people are reading what is here (about 1000 visits a day).

And to be honest even reading the above comments has made me perform one or two additional techniques this week that I perhaps may not have done without reading them. If only to assess and test out everyone's thoughts in the clinic that makes the forum well worth while because the patient is getting the direct benefit.

Thanks for your input

Dear somasimple,
Mobilisation of facet joints is a movement intended to bring about the release from tightness of any spinal joint involved in a protective response . The nature of the protective response is that the smallest groups of muscles will increase in tone to hold still the facet joint involved in order to reduce movemnts generally and begin a cascade that ultimately will be revealed as painful. It is not necessary to provide movement to facet joints such that only that structure is move and absolutely nothing else is moved , pushed or pressured in some way. To assume this would be necessary would be to miss the point of mobilising.
When appropritely trained hands apply passive movement effects to facet joints , it will be obviously necessary to exert pressure through muscle and other soft tissue. Sufficient pressure to cause movement however does not usually require a lot of effort. It is common however for my students to feel fatigue in their thumbs untill a certain amount of strength has been aquired.
Further on this subject as I am able
Cheers

[somasimple]

Dear Geoff,

You miss my point there.

1/You may think that your point of action is situated on a facet joint but you said as I did that you need absolutely before an eventual action there to put your thumb on skin (it is sensitive), on muscle (it is sensitive) then it is possible to have an action by these sensitive structures prior the facet joint.

2/ A force applied on a structure (facet) needs a reaction of the structure or you may pass through the body. Sorry but it is only physics and physics needs strict rules. So, in my view, even if you had a chance to apply a force/action on a facet joint then you have no chance to know where the reactions forces are applied. BTW, you can't act on a unique facet joint or physics lies.

3/ One more time, if I agree with a quick fix I'm not sure of its duration since the patient suffers your action and the brain do not learn anything. Imagine the patient having a muscular anticipation (a common thing with LBP) does that change the brain process? NO! A better way is to tell patient to move these voluntary muscles in a safe way then patient learns something.