MEDICAL MASSAGE vs. 30 YEARS OF PAIN AND MISERY

Nancy McNamara, CMMP, LMT, is one of the newest graduates from our Medical Massage Certification Program. For more than 2 years, we’ve worked with Nancy, and we gradually built her professional expertise and clinical thinking. The results are exceptional, and therapists may observe them firsthand while reading Nancy’s submission to JMS’s Case of the Month Contest.

Please pay attention to the depth of Nancy’s evaluation skills and how carefully but with clinical precision she was able to peel off layers of soft tissue dysfunctions and years of pain and suffering. Seeing the profound impact our former students are able to make on patients’ lives makes us proud of the effectiveness of SOMI’s program.

By Dr. Ross Turchaninov
JMS’s Editor in Chief

MEDICAL MASSAGE vs. 30 YEARS OF PAIN AND MISERY

By Nancy McNamara, CMMP, LMT

A gentleman in his mid-60s (Mr. J) came to my office on 7/01/19 with Right Side Lower Back Pain (Lumbalgia). Periodically he also experienced pain radiation to the dorsal surface of both feet along the 3rd and 4th phalanges and bilateral pain and numbness in his feet. All his life, he worked in a sitting position as a CPA.

The pain and numbness in his feet, which are mostly centered around both greater toes, have a 30-year history after he had a Laminectomy to relieve pressure from bulging L4 and L5 discs while he was in his 30s. Later on, the patient had two more surgeries to remove debris from the original back surgery and a third surgery to clean up scar tissue.

His recent symptoms were diagnosed by a neurologist as not being associated with impingement of the spinal nerve at the level of the spine, but rather from peripheral nerve compression by muscles. The patient was prescribed Zoloft as a muscle relaxant. He complained that the medication did nothing to resolve his pain and cramping but made him “feel sick and psychotic.”

Originally, his symptoms began in the right leg and foot and after 10 years of occurring on and off, “moved to the left.” He clearly remembers that symptoms in the right foot manifested themselves approximately three years after his laminectomy for L4 and L5.

Over the years, the patient was treated by a number of physicians and physical therapists but didn’t get any stable clinical results. For the last 8 months, the patient had been confined to his recliner and could not even walk around a grocery store without severe cramping in both legs and pain and sensory deficit in his feet.

EVALUATION

Complaints

His current complaints are pain on the dorsal surface of his feet, more prominent on the right; bilateral lower back pain especially prominent on the right; right gluteal pain (the patient said “right here in a circle” as he pointed to the area over the right posterior superior iliac spine and gluteal area).

Evaluation of the Soft Tissues in Lumbar Area

First of all, I wanted to rule out acute compression of the spinal nerves in the last lumbar segments. A Vertical Compression Test on the spinous processes of L4 and L5 didn’t trigger any new sensory abnormalities (pain, burning, tingling, numbness) down to the leg and foot.

a. Fascia

My next step was to examine fascial tension in his lower back. Both parts of Kibler’s Technique pointed to severe tension accumulation in the first level of Connective Tissue Zones (dermis of the skin) and the second level of connective tissue zones (superficial fascia, which covers the lumbar erectors) at the L4-L5 level. I was unable to even barely pinch a fold of skin in these areas.

Examination of the third level of connective tissue zones (i.e., deep fascia) using the Lateral Shift Technique indicated the presence of great tension in the deep fascia which separates lumbar erectors from the quadratus lumborum muscle. In other words, the patient developed heavy scarification of the deep fascia, with severe adhesions formed between the two muscle layers that replaced the normal network of fibrotic bridges with high elasticity.

b. Skin

The Sensory Test to examine the presence of cutaneous reflex zones didn’t show significant differences between right and left sides, but this finding was uninformative since the patient had already exhibited profound sensory abnormalities and simply couldn’t differentiate the intensity of his sensations during the test application.

What was obvious was the result of the Dermographism Test. It pointed to severe parasympathetic tone predominance in the lumbar area which was an additional indicator of the long presence of chronic pain, which actively disturbed the balance within the autonomic nervous system.

c. Skeletal muscles

Next, I detected the presence of active trigger points and great tension in the lumbar erectors and quadratus lumborum muscles.

d. Periosteum

Examination of the periosteum indicated very active periosteal trigger points along the right iliac crest, especially at the insertions of the erectors and QL muscles.

However, these local findings in the patient’s lower back can also be the results of spinal surgery done more than 30 years ago.

Examination of the Soft Tissues in Lower Extremities

Examination of the gluteal area indicated the presence of active trigger points in gluteal muscles. An especially active trigger point was detected in the right piriformis muscle.

Also, the patient exhibited such significant tension in his hamstrings and posterior leg muscles that Compression Test as well as Tinel’s Test for both soleus canal (for tibial nerve) and tarsal canal (for common peroneal nerve) were very positive.

Thus, it was almost impossible to determine whether the Tibial nerve, the Peroneal nerve, or both were compromised. So according to Peroneal Nerve Neuralgia and Tibial Nerve Neuralgia protocols recommended by the Science of Massage Institute, I needed to start with the Piriformis Protocol as I previously ruled out acute disc compression of L4 and L5 spinal nerves.

MEDICAL MASSAGE THERAPY

For the first 5 sessions, I used the Piriformis Syndrome Protocol suggested by SOMI. However, I started with addressing the lumbar area concentrating on the paravertebrals and QL, giving more attention to the right side. During these sessions, I also worked on the hamstrings, adductors, and posterior leg muscles, following the pathways of the sciatic as well as tibial and common peroneal nerves. I finished each session with PIR for the QL and piriformis muscles. I used twice-a-week sessions.

Even after the 2nd session the patient began to feel less pain and discomfort in his lumbar erectors, QL and gluteal muscles. As soon as tension in the QL muscle started to diminish, I noticed less tension in all his gluteal muscles, especially piriformis. It gave me additional confidence that the initial cause of his symptoms was in the lumbar area and it was responsible for reflex zones formation down to the leg. As a result of a 30-year history of chronic pain, the initial reflex reactions in his lower extremity developed into independent clinical problems which masked the initial trigger.

By the 3rd session, much of the tension in the muscles of his lower legs had dissipated and I was now able to clearly determine that it was the Common Peroneal nerve part of the Sciatic nerve being compressed by peroneal muscles and tibialis anterior bilaterally. The tension in the soleus canal and consequent tibial nerve irritation was just a reflex reaction to the years of chronic pain and tension.

I based my assumption on the fact that Tinel’s Test was still very positive under the fibular head (for common peroneal nerve) while it was now negative over the soleus canal (for tibial nerve). Also, application of electric vibration below the fibular head sent a clear shock wave all the way into the toes of the right foot. Finally, there were very painful periosteal reflex zones formed along the pathway of the common peroneal nerve from the lateral calcaneus, talofibular ligament, and all the way along the 5th metatarsal bilaterally, but more prominent on the right.

Another encouraging factor was that during the 3rd session the patient complained of “circular pain” in the right QL and gluteal muscles becoming “much duller.” I encouraged him to continue homecare stretches for the piriformis and right QL.

During the following sessions, I began to focus on bilateral application of the Peroneal Nerve Neuralgia protocol while continuing to treat tibialis anterior and posterior leg muscles. Tibialis proved to be very tight and almost heavily fibrotic. I included therapy of cutaneous reflex zones with skin friction, pinching, skin rolling along the lateral leg all the way down to the dorsal aspect and toes on both feet.

Mr. “J” has been faithfully seeing me for treatments 2x a week, 3-5 days apart since 7-01-19. He does all his suggested homework exercises with enthusiasm. The following is a list of his many “little victories” he has experienced:

1. By his 6th session, Mr. J reported that the ROM and mobility of his ankles “feels more loose,” and he felt more improvement in walking after the 4th treatment.
2. By the 7th session he reported a 50% decrease in tingling in the feet and toes after I started to engage his periosteal reflex zones with Cyriax’s friction over the lateral calcaneus, lateral ankle, and talofibular ligament to the 5th metatarsal bones in both feet.
3. By the 8th session Mr. “J” reported that his feet got sore, but rubbing them brought relief from painful burning. He also noticed the numbness in both toes starting to resolve.
4. By the 9th session, there was less discomfort, and the numbness moved from the 4th toe to the middle toes bilaterally. Walking feels less like “walking on pebbles.”
5. By the 10th session Mr. “J” was able to walk better and “even my wife noticed improvement in my gait and walk”. He also noticed that “feet feel more like flesh.” I observed that the once-tough fibrotic firmness along the peroneal group and tibialis anterior became more pliable. He also reported that during PIR therapy and passive stretching of the peroneals and Tibialis Anterior, his muscles “has more bounce to it.”

We started to see each other once on a weekly basis:

1. August 13th: Mr. “J” was able to cross an entire store without employing a slow, cautious gait in which he usually curls his toes with each step. Pain is resolved, but he still has tingles and numbness.
2. August 23rd: Mr. “J” begins stretching 3 times a day after reviewing proper techniques for homework exercises. His “new favorite hobby is to rub my feet because it feels so good!” I observed that now Trigger Point Therapy requires a small fraction of the time to control tension and residual discomfort!
3. September 19th: Mr. J played pool for 6 hours! “rubbed my sore feet and went to dinner!” A minor flare-up was controlled by work on the lower back and gluteal muscles bilaterally. I quickly provided TM and passive stretching before resuming the PNN protocol.
4. September 23rd: Mr. J begins planning for a more active lifestyle. “I’d like to do something all day.” He again requested attention to the lower back and gluteal muscles before application of the Peroneal Nerve Neuralgia protocol.
5. September 30th: Mr. J had an active 3-day weekend of “doing too much” yardwork that included landscaping and the next day 6 hours of a billiard contest. As a result, he had two days of relapse. We were able to quickly control it. Lately, Mr. J reported one last remarkable victory: “Ankles feel much better! Feet feel really good!” He now rubs his feet with a gua sha stone, does his exercises, and rolls his ankles in circles: “Feels like walking in slippers!”

After I consulted with Dr. Ross Turchaninov, he suggested adding TENS unit application at home along the strategic points of the common peroneal nerve and lumbar decompression by inversion table. Mr. J has accepted these two amendments and had additional improvements!

So how did this all happen? It is my theory that years of sitting at a desk working as a CPA and his various hobbies resulted in compression and bulging of the L4 and L5 discs which led to the laminectomy while in his 30s. Lack of correct soft tissue rehabilitation in combination with subsequent spinal surgeries triggered common peroneal and later tibial nerve irritation and adhesions formed between layers of the soft tissues in his lower back, legs and feet. As a result, normal mobility between layers was greatly affected, additionally contributing to the nerve irritation and ROM restriction. Eventually, his symptoms progressed to almost complete disability in both feet. I am sure that it was his right QL which at one point threw off lumbar balance affecting erectors and right piriformis. With time, it led to entrapment of the sciatic nerve and later its common peroneal branch.

Medical Massage saved my patient from disability and brought him back to an active, productive life!

ABOUT THE AUTHOR

Category: Case Studies

Tags: JMS 2019 Issue #4