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Hi Frederick,

How do you propose a treatment like prolotherapy would work in this case? Where would you inject?

Cheers,
Kent

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Cheers,
Kent

Performance Podiatry & Physiotherapy

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Dear Kent

I don't do prolotherapy, but since Dr. Hackett developed it many years ago, it has often been used to treat various problems in the back, including some of the causes of sciatica.

You would need to find someone, usually a GP, who specialises in this form of treatment. There is a great deal written about prolotherapy, but for a start you can try: Getprolo.com

Cheers

Frederick

hi kent, how has it been going with this patient? any further results in?

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Hi Frederick:
You sound a little defensive. Please, no need to be.
All I meant was that if you decide BEFORE you order a test that the results are not going to change your Dx or Tx, then don't order it. That's all.

"As to your personal history with your ex-wife, I don't think we need to know."

You're choice...but it's pretty interesting. Would make a hell of a movie! haha
Steve

Kent:
It's been several months.
I'm very curious as to how this patient responded to further diagnostics and/or treatment.
Steve

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DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

I would like to add another possibility that has not yet been offered, although I believe that Dr. Kirby did cover this generally.

Given the timing of the event, exertion induced loss of subjective strength during intense activity such as running, intermittent neuropathy in a sciatic distribution and constant sacroiliaic, buttock region/hamstring discomfort, I would rule out spinal stenosis vs. facet pathology/neuroforaminal encroachment in the lumbar spine. Either case could cause the radiculopathy that Dr. Kirby discussed.

I have also seen patients with symptoms that are not entirely bilateral in early spinal stenosis. As they progress the typical neurologic intemittent claudication occurs bilaterally; cramping and loss of strength in the leg and lower extremity brought on by exertion and relieved by resting in the Valsalva position.

He may also have a piriformis syndrome as was mentioned, in about 10% of the population (women > men) the sciatic nerve courses through the muscle belly. Any activity that increases abductory motion and extension in the hip and varus at the knee lights these people up.

I would suggest referring him out to an orthopedic spinal specialist for a complete workup in addition to the neurologist. He should have both the spinal canal dimensions and the neural foramen evaluated for patency.

I have a feeling that he is not revealing all of the relevant history to you. I treat runners and endurance athletes they are notorious for slowly giving out all of the details of their concern. I believe that this is because many exhibit a strong case of denial and minimization of symptoms because they do not want to have any of their activities precluded or modified. I would again ask him about his lower back history.

On the other hand they present to the office loaded with material and seem to understand medical terminology greater than the average patient. This leads me to believe that they are doctor shopping in some cases for an answer that is acceptable to them, regardless of what is most appropriate for their case. This is what Dr. Sarbes is referring to and I find a lot of truth in this.

I also agree is what Dr. Kirby points out and that is that only another runner (really any athlete) really appreciates what this activity means to their daily life. It IS their daily life and of the many doctors out there who claim to specialize in treating these certain athlete population, very few can truly commiserate their needs and feelings. Regardless of what the etiology of this gentleman’s complaint he wants a professional who “gets him” and can aid him in being able to continue running. I don’t think that this is impractical for most patients. I like to call it “the good side of selfish” because as a cycling enthusiast I understand that mindset.

In this case though based on what I see in the gait videos I feel he has an antalgic gait favoring the right side. Definitely something is affecting his gait running and walking.

He doesn’t appear to propulse off of the right great toe and instead circumducts the right foot at push-off and during early swing phase. Perhaps he has some first ray insuffiency or peroneal weaknees, I would suspect FHL looking at the films but Kent already ruled this out.

Kent is his right foot Ficke angle increased? He appears to be toeing out on the right and I see this on the short leg side frequently in a functional LLI. Along with that the pelvic rotation will cause tightness and shortening of the gluteals, hamstrings and spasticity of the quadratus lumborum and deep spinals musculature thus altering normal hip motion during gait.

Patients with this type of gait are typically right sided LBP, right LLI due to posterior nutation of the ilium and as time progresses they will lean away to the left and favor the right LE. This is I believe in line with PodAus’ suggestion of a functional mechanical discrepancy. I tend to agree.

Lastly if this is a low back complaint then I must give large kudos to Dr. George for suggesting a course of chiropractic care if indicated (he also noted the left sway (which I believe may be antalgic in nature). Our professions could truly complement each other in my opinion. I cannot recall an early sciatic or LBP patient without objective weakness that I have treated over the years who did not have an excellent outcome with manipulation and PT.

Please don’t beat me about the head for my views; I am only expressing a humble opinion and joining the fun….

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"If we all worked on the assumption that what is accepted as true is really true, there would be little hope of advance." - Orville Wright

David G. Wedemeyer, D.C., C.Ped.

I would definitely be seeking sports chiropratic care and monitoring the functional outcome (change in running 'performance').

How is this patient progressing?

Cheers,

Paul Dowie

Unfortunately still no word from this patient. I believe he is still waiting to see the neurologist. I'll be sure to update everyone as soon as I know something. Thanks for all the suggestions and comments so far.

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Cheers,
Kent

Performance Podiatry & Physiotherapy

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