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Intermedial Dorsal Cutaneous Nerve Pathology

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  #1  
Old 23rd March 2012, 09:01 AM
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Default Intermedial Dorsal Cutaneous Nerve Pathology

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Looking for some advice for something that is something I am struggling to devise a treatment plan for.

Diagnosis of this 40 year old race walker is Intermedial Dorsal Cutaneous Nerve tension/compression.

I have given advice regarding alteration of shoe lacing patterns to reduce compression and given some padding either side of the nerve pathway to ensure that there is no pressure on the nerve.

However, the question I have is; are nerve glides appropriate and successful for intermedial dorsal cutaneous nerve tension.

I am pretty sure that the compression is a factor but based on the fact that the patient experiences more problems walking downhill and the symptoms are relieved going uphill, I think that tension is the issue.

I would appreciate any comments or if anyone can offer any other advice, I would be most grateful.

Kind regards,

Robin

Just before anyone says anything, I have always thought it was the intermediate , not intermedial. Curiously, the Grays diagram says intermedial?! http://en.wikipedia.org/wiki/File:Gray836.png
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  #2  
Old 23rd March 2012, 08:14 PM
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Default Re: Intermedial Dorsal Cutaneous Nerve Pathology

how did you arrive at your dx ?

regards

Martin
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Old 24th March 2012, 12:13 PM
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Default Re: Intermedial Dorsal Cutaneous Nerve Pathology

SLR and slump accurately recreate symptoms. Percussion of the nerve on the dorsum of the foot also accurately replicates the symptoms.

Eliminated all other possibilities than I can test clinically - don't have access the US or MRI

Regards,

Robin
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Old 24th March 2012, 01:49 PM
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Default Re: Intermedial Dorsal Cutaneous Nerve Pathology

what are patient's symptoms? any TMT or MTJ osteophytes present?

Cheers Martin
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Old 24th March 2012, 02:15 PM
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Default Re: Intermedial Dorsal Cutaneous Nerve Pathology

Quote:
Originally Posted by RobinP View Post
Looking for some advice for something that is something I am struggling to devise a treatment plan for.

Diagnosis of this 40 year old race walker is Intermedial Dorsal Cutaneous Nerve tension/compression.

I have given advice regarding alteration of shoe lacing patterns to reduce compression and given some padding either side of the nerve pathway to ensure that there is no pressure on the nerve.

However, the question I have is; are nerve glides appropriate and successful for intermedial dorsal cutaneous nerve tension.

I am pretty sure that the compression is a factor but based on the fact that the patient experiences more problems walking downhill and the symptoms are relieved going uphill, I think that tension is the issue.

I would appreciate any comments or if anyone can offer any other advice, I would be most grateful.

Kind regards,

Robin

Just before anyone says anything, I have always thought it was the intermediate , not intermedial. Curiously, the Grays diagram says intermedial?! http://en.wikipedia.org/wiki/File:Gray836.png
Robin:

Race walking uses very exagerrated, long stride lengths which may, during contact phase, excessively plantarflex the ankle, especially going downhill. Even though I have never heard of the intermediate dorsal cutaneous nerve being injured in race walkers, it seems likely that excessive ankle plantarflexion motion is causing the issue.

I would instruct the athlete to loosen all their shoe laces on the affected side and not race-walk downhill until the symptoms improve. Maybe he can stick to flat workouts for now or, if he needs to go downhill, have him slow down some to avoid excessive ankle plantarflexion. Topical Voltaren gel three times a day may also help.

Hope that helps.
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Sincerely,

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Old 27th March 2012, 09:55 AM
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Default Re: Intermedial Dorsal Cutaneous Nerve Pathology

Quote:
Originally Posted by RobinP View Post
this 40 year old race walker is Intermedial Dorsal Cutaneous Nerve tension/compression.

However, the question I have is; are nerve glides appropriate and successful for intermedial dorsal cutaneous nerve tension.

I am pretty sure that the compression is a factor but based on the fact that the patient experiences more problems walking downhill and the symptoms are relieved going uphill, I think that tension is the issue.

I would appreciate any comments or if anyone can offer any other advice, I would be most grateful.

Kind regards,

Robin
The intermediate dorsal cutaneous nerve is the peroneal nerve's terminal and lateral branch. The nerve supplies the foot dorsum laterally and to the 3-4-5 toes.
Is that the isolated location of the patient's problem?

Have you tried anesthetizing the IDCN, possibly prior to a racewalk, to see if all symptoms are eliminated or to expose a larger diagnostic dilemma?.

Is there any numbness or other paresthetic symptomatology or only pain?
I would think pure compression would produce some numbness in addition to pain in a racewalker.

I would intensify my pontoon pads and incorporate them into the patients shoes so that they are always in place. Also, I would suggest a racewalking shoe with a higher throat.

Biomechanically, if this patient has a flexible forefoot FFT, I would consider foot type-specific orthotics and compensatory threshold training of peroneus longus in order to increase medial column grf and reduce lateral column grf from causing tissue stress and excess movement within the shoe that may be participatory
.
If the patient has a rigid forefoot FFT than I would suggest that space occupation is the culprit and focus on that.

Dennis
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  #7  
Old 27th March 2012, 12:44 PM
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Default Re: Intermedial Dorsal Cutaneous Nerve Pathology

Quote:
Originally Posted by Mart View Post
what are patient's symptoms? any TMT or MTJ osteophytes present?

Cheers Martin
Hi Martin,

There were no palpable osteophytes which is not to say that there weren't any so good suggestion

Thanks

Robin
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Old 27th March 2012, 12:50 PM
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Default Re: Intermedial Dorsal Cutaneous Nerve Pathology

Quote:
Originally Posted by Kevin Kirby View Post
Robin:

Race walking uses very exagerrated, long stride lengths which may, during contact phase, excessively plantarflex the ankle, especially going downhill. Even though I have never heard of the intermediate dorsal cutaneous nerve being injured in race walkers, it seems likely that excessive ankle plantarflexion motion is causing the issue.

I would instruct the athlete to loosen all their shoe laces on the affected side and not race-walk downhill until the symptoms improve. Maybe he can stick to flat workouts for now or, if he needs to go downhill, have him slow down some to avoid excessive ankle plantarflexion. Topical Voltaren gel three times a day may also help.

Hope that helps.
Just an update on this patient, I spoke to her tonight and she used her trainers with the central lace loops skipped to reduce dorsal compression in addition to the padding I had added to create a relief channel and this allowed her to do a 20 mile walk with no problems.

I have advised her tonight to try(as much as possible) to limit her downhill walking and if downhill is necessary, to shorten step length. She has been icing it as I suggested before and this also seems to be helping.

Any opinions on ending to the physio for nerve glides?

Thanks to all that have replied. Dennis, I'm sorry but I cannot follow your terminology so I am unable to really answer the questions

Thanks

Robin
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  #9  
Old 27th March 2012, 12:57 PM
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Default Re: Intermedial Dorsal Cutaneous Nerve Pathology

Quote:
Originally Posted by RobinP View Post
Just an update on this patient, I spoke to her tonight and she used her trainers with the central lace loops skipped to reduce dorsal compression in addition to the padding I had added to create a relief channel and this allowed her to do a 20 mile walk with no problems.

I have advised her tonight to try(as much as possible) to limit her downhill walking and if downhill is necessary, to shorten step length. She has been icing it as I suggested before and this also seems to be helping.

Any opinions on ending to the physio for nerve glides?

Thanks to all that have replied. Dennis, I'm sorry but I cannot follow your terminology so I am unable to really answer the questions

Thanks

Robin
Robin:

Personally, I have found physical therapy to not be helpful for these types of pathologies and, in fact, any manipulation of the nerve can exacerbate symptoms. Icing and avoiding compression and tension of the nerve should, over time, help with the symptoms.
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Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

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107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
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**************************************************
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Old 27th March 2012, 12:58 PM
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Default Re: Intermedial Dorsal Cutaneous Nerve Pathology

Quote:
Originally Posted by RobinP View Post
Dennis, I'm sorry but I cannot follow your terminology so I am unable to really answer the questions
Robin
No problem.
I'm pleased your patient is doing well.

Dennis
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  #11  
Old 27th March 2012, 01:01 PM
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Default Re: Intermedial Dorsal Cutaneous Nerve Pathology

Quote:
Originally Posted by Kevin Kirby View Post
Robin:

Personally, I have found physical therapy to not be helpful for these types of pathologies and, in fact, any manipulation of the nerve can exacerbate symptoms. Icing and avoiding compression and tension of the nerve should, over time, help with the symptoms.
Ok many thanks for the advice. I shall update when I hear more.

Regards

Robin
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