In every issue of our journal you will find Case of the Month which we will select among submitted ones. Everyone who is using Medical Massage protocols in their practice may submit their cases for the review and we will share with our readers the best one in every new issue.
Unfortunately for this issue of JMS, we did not have an interesting contribution from our readers. Therefore, we decided to share with you one of the cases from our clinic in Phoenix, Arizona. What is interesting about this case? We always emphasize important facts for students and practitioners. It does not matter what your textbook or seminar you took told you to do. Every patient is different, and in difficult cases, especially when attempts by other health practitioners were already made, the clinical success depends on the ability of the practitioner to use learned information as a basis but also to look beyond the recommended routine. In the presented case, just a small variation in the clinical test allowed us to restore the health of the patient.
MEDICAL MASSAGE vs UNEXPLAINED PAIN IN RIGHT LOWER EXTREMITY
Male, 47 works as a barber. Four months ago, he started to feel tingling on the lateral surface of the right leg. After a long day, the same sensations of tingling occurred along the dorsal surface of the foot. These symptoms were intermittent. Within the following two weeks, he started to feel numbness and a burning-pain sensation in the same areas especially on the lateral leg.
He went to his family physician who diagnosed him with Sciatica, prescribed muscle relaxants, and sent him to physical therapy. A physical therapist diagnosed the condition as Sciatica as a result of spasms in piriformis muscle. After two weeks of physical therapy, he started to have excruciating pain originating in the right gluteal area, which was shooting all the way down to the top of the foot. At this point, he stopped working because he was unable to put pressure on the right leg.
An MRI did not show significant changes in the lumbar spine and patient. The patient was referred to a Pain Clinic where Vicodin and later Oxycodone were prescribed. The patient was very unhappy about these medications because they made him feel like a “zombie”. The patient also visited a chiropractor but after the second session the intensity of the pain had increased to an intolerable level, and he discontinued further therapy. Several sessions of acupuncture helped decrease the pain intensity to a moderate level. However, the patient was able to work only for two to three hours per day.
The patient was referred to our clinic by one of our patients. At the very beginning of the first examination session it was very obvious that he was under a lot of stress, and had begun losing hope because various treatments had not relieved his pain and suffering.
Examination of the patient showed that he had significant sensory (numbness, tingling, burning pain) and motor (muscle weakness of the peroneal group) abnormalities along the distribution of the common peroneal nerve. The examination of the right gluteal area showed a very positive Trigger Point Test for piriformis muscle. The Straight Leg Rise Test was positive as well.
The examination of the lower back, right sacrum and sacroiliac joint did not show any significant abnormalities. There were moderately active trigger points in the gluteus maximus muscle. We confirmed the previously established diagnosis of Piriformis Muscle Syndrome and proceeded with an application of medical massage protocol.
We used a three-sessions-per-week approach with a four-day break after the third session to observe any results. After each session, the patient felt significant pain relief but after the four-day break, the pain returned but with less intensity. We repeated the same protocol two times with the same results. Considering the difficulty of the case, we decided to recommend to the patient a cortisone injection into the piriformis muscle. After the injection, the patient had only mild tingling on the right lateral leg and was able to return to work. However, in two weeks the symptoms returned with the same intensity.
At this point it was clear that, as other health practitioners who worked on this patient, we were on the wrong path. Considering that the piriformis protocol had not worked and the cortisone injection didn’t provided a stable clinical result, it was obvious that something happened in the area above the piriformis muscle.
There are only five potential areas above the piriformis muscle where the spinal nerve can be irritated: intervertebral disks on the level L4-L5 and L5-SI, the short rotators on the same levels, the lumbar erectors at their insertion into the sacrum and the right sacro-iliac joint (SI joint), injury to the sacroiliac ligament. Despite our previous careful examination of all these areas, we decided to re-evaluate the patient as if we were seeing him for the first time. Starting from this session, the patient was not required to pay for the treatments.
Intervertebral disk pathology was ruled out by an MRI, there was no history of trauma or significant lumbar strain affecting the sacro-iliac ligament. Plus, the symptoms had developed slowly over the course of one month, which excluded strain of sacro-iliac ligament that can trigger symptoms very quickly. Palpatory examination of the short rotators and the pattern of pain distribution did not indicate their involvement.
Now we concentrated on the examination of the belly and tendinous part of right lumbar erectors. This palpatory examination did not show any abnormalities either. Our final target was the right SI joint. All tests were negative including the Compression Test for L5 spinal nerve irritation under the SI joint. However, during re-application of the same test when the angle of applied pressure was slightly changed (from the commonly recommended 45 degrees), the patient felt a sever shooting pain to the foot. Considering that L5 is one of the major contributors to the innervation of piriformis muscle, it was clear that the spasm in the piriformis muscle was a secondary pathology due to the irritation of the L5 spinal nerve under the right SI joint. Four sessions of medical massage protocol targeting the right SI joint completely eliminated the clinical symptoms, and the patient was able to return to full-time work.
Compression Test (CT) for L5 Spinal Nerve
Now, let us consider the application of the CT and its variation that we experienced with this patient. The L5 spinal nerve is the only spinal nerve which at its exit from spinal cord is attached to the thecal sack. The spinal cord is inside of the thecal sack. This attachment makes L5 spinal nerve less mobile. Any pressure or stretching of the L5 spinal nerve places it in a very unfavorable position because the nerve lacks the ability to give under even mild pressure or stretch.
If, let’s say, the SI joint on one side is even slightly disbalanced, the L5 spinal nerve will be mildly irritated. In such case, the patient will complain about sensory or/and motor abnormalities in the areas of the body at the end of the nerve. Later, if pressure on the nerve increases the symptoms will originate in the lower back and radiate down along the same route. However this was not our patient’s case.
The CT is 100% accurate and sensitive. The video below shows the anatomy of the area we just discussed and the recommended application of the CT on the model of the spine. As you can see, the thumb must be placed at 45 degrees and the direction of application is a critical factor. The pressure must be directed to the area where the iliac bone meets the sacrum and forms the SI joint. Thus, the CT does not target the SI joint but rather the area under it. The pressure should be significant to reach the L5 spinal nerve and additionally stretch the already irritated nerve.
In the video below, we show the initial application of the CT, which did not indicate the L5 spinal nerve involvement under the right SI joint. The second part of the video shows that small more vertical change in the angle of the applied pressure (from the recommended 45 degrees) immediately indicated that the CT was positive. This simple fact completely changed the treatment protocol and restored the patient’s health.
Category: Case Studies , Medical Massage