In every issue of our journal, you will find a Case of the Month, which we will select from among the submitted cases. Everyone who is using MEDICAL MASSAGE PROTOCOLS in their practice may submit their cases for review, and we will share with our readers the best one in every new issue.
This contribution is from a member of our Editorial Board, Stephen Ryason, MMT. This case is a great example of the clinical impact medical massage can have on some patients when it seems all other treatment options have failed. In the Case of the Month section of JMS, we always try to expose our readers to a unique feature of medical massage – the critical importance of a successful diagnostic evaluation of the patient before treatment starts.
What would hypothetically happen to this patient if the practitioner didn’t have enough confidence in the examination of the patient and followed the already established diagnosis of Plantar Fasciitis? The practitioner would review the DVD or textbook that describes the massage protocol for Plantar Fasciitis because the diagnosis was already established. With this very common approach to the treatment, the practitioner would fail, just as the podiatrist and physical therapist did. They made a critical mistake by following the patient’s complaints (pain in the foot and leg) without even considering other causes, and they didn’t conduct a proper evaluation. Local pain is not the ultimate guide to establishing the correct cause of the pathological abnormality, and Stephen gives a great example of it in his contribution.
Also, notice how wisely Stephen developed an individual MEDICAL MASSAGE PROTOCOL for this particular patient. He combined three separate MEDICAL MASSAGE PROTOCOLS for Piriformis Muscle Syndrome, Tibial Nerve Neuralgia and Plantar Fasciitis during the course of medical massage, restoring the patient’s health step by step. First, he freed the nerve from the pressure; later, he addressed the inflamed tibial nerve while eliminating local abnormalities on the foot that had developed secondarily.
Thus, this case is an illustration of free thinking and clinical open-mindedness by a massage practitioner who didn’t blindly follow the already established views and was able to make a huge difference in the patient’s life by using correct evaluation and medical massage treatment.
MEDICAL MASSAGE vs. “MYSTERIOUS” FOOT AND LEG PAIN
The client is a 62-year-old female who initially contacted me by telephone through another client’s referral. We briefly discussed her issues, and I set up a consultation for the next day.
Initial Complaints
She arrived at my office in obvious discomfort. She was wearing orthopedic shoes, and when she walked, her hands were outstretched sideways like she was on a tightrope. She also took very small, careful steps, as if she were walking on eggshells.
Her symptoms included the inability to apply any pressure on the medial arch of each foot or on the big toes, causing her to walk on the outsides of her feet. She stated the foot pain was strongest in the morning, with the worst pain occurring when she first woke up and attempted to stand. She said that on some mornings the pain was so severe that she had to crawl on her hands and knees to the bathroom. She also stated that her calves were always aching, that she suffered from frequent cramping, mostly at night, and that she had intense pain behind the knee during the daytime.
She had seen a podiatrist, who had diagnosed her with Plantar Fasciitis aggravated by heel spurs in both feet. The first treatment she received was to fit her with orthotics. These were of limited help, primarily because they were so uncomfortable she wouldn’t use them. Later, the podiatrist prescribed physical therapy. When she started PT, her primary complaint was her feet, but after 6 sessions, the pain in her calves and behind her knees increased significantly, so she stopped going. Next, the podiatrist administered 2 cortisone injections to each foot over a 2-week period. The first injections gave her noticeable relief for almost a week until the pain returned, and the second injections provided no relief at all. She was depressed, in constant pain, and didn’t know what else to do when she came to me.
Clinical Examination
Since I had a doctors’ diagnosis, I began an evaluation according to the tests recommended in the Video Library for Plantar Fasciitis (PF) and Calcaneal Spur Syndrome (CSS). The tests were positive and confirmed the clinical picture of PF/CSS in both feet.
However, the treatment according to this diagnosis wasn’t successful. This is why I decided to examine her back, hips, and legs. I used the evaluation tests from the Video Library associated with Piriformis Muscle Syndrome (PMS), Sciatic Nerve Neuralgia (SNN), and Tibial Nerve Neuralgia (TNN). Tests were positive for bilateral PMS, negative for SNN, and positive for bilateral TNN.
My evaluation pointed to a completely different cause of her clinical symptoms. It seemed that her severe foot and leg pain was the result of irritation of the tibial portion of the sciatic nerve in the gluteal area by the piriformis muscle and in the soleus canal by the soleus and gastrocnemius muscles. The clinical symptoms of PF and CSS were just consequences of nerve irritation. I told her I thought I could be of help and recommended an initial treatment protocol of 2 treatments a week for 3 weeks. We began treatment the next day.
MEDICAL MASSAGE PROTOCOL
I went home and reviewed the protocols for PMS, TNN, and PF/CSS in the Video Library. I determined that during the first two treatments I would concentrate primarily on the PMS protocol with some work on the feet. After these two treatments, her response to PMS testing was greatly improved, and she said she thought her feet felt better.
I continued with the full PMS protocol for one more session, and then began using the protocols for TNN and PF/CSS for the next two sessions. Both sessions were very productive. I determined that the primary location of TN irritation was the soleus canal and concentrated my work there. I also continued to work on the feet to prepare them for the PF/CSS protocol.
I conducted three more sessions using the PF/CSS protocol. We achieved significant improvement with each session, and after the 3rd session, she was 90% pain-free. I told her I didn’t want to see her for 7 days, and I wanted her to keep a record of how she felt through the week.
When she returned, she stated that she still had some discomfort, but no pain. I recommended she contact her podiatrist to see if he would prescribe a dorsiflexion boot for her to wear at night. This she did, and she continued with therapy once a week for 3 weeks. As of the time of writing, she still has some occasional mild discomfort, mostly in the morning, which is stronger if she doesn’t wear the boot at night. I still see her once every 2 weeks for maintenance.
Category: Case Studies
Tags: JMS 2011 Issue #1
