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Pain at the dorsum of (R) foot

Hi everyone, I hope the weekend is going on smoothly.

A 4 year old girl visited my clinic on account of pain at the (R) leg and sole of the foot. Mother reported the pain started after she received injection on her gluteus muscles about 3 months ago following malaria treatment. Initial treatment for the pain was the use of (oral and topical) analgesic. However, there was little improvement but the pain still persist. On examination, there was nil atrophy, nil motor weakness and nil deformity on the affected limb. There was pain on palpation at the anterolateral part of the lower leg and dorsum of the foot. My clinical diagnosis was injection palsy/Traumatic injection neuritis (Peripheral nerve injury). Patient has received 3 sessions of Physiotherapy using TENS(MH6000 combo), Massage therapy, Physical agents and therapeutic exercises. With the use of TENS on the anterolateral group of muscles(the right lower leg), after two visits, pain intensity has reduced at the anterolateral muscle compartment of the lower leg but child still persist pain at the sole of the foot. How best can I achieve reduction in pain sensation at the sole of the (R) foot?

Thanks in advance!

Fasuba Ayobami Debowale

4 months ago

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fisioniki289
fisioniki289

egbonfasuba264 said: This is beautiful, especially with the Egg-Chicken concept! However, my management were more of stretching techniques and postural re-education.

Perfect! WOrk with postural and stretching... Work on all flexors of the foot, common flexor, plantaris, soleus, quadratus plantae, abductoris allucis...

egbonfasuba264
egbonfasuba264

fisioniki289 said:

egbonfasuba264 said:

fisioniki289 said:

Have you tested the pain? I mean... is related to some functional or muscular test? May it be a trigger point activated? Soleus... plantaris...

Anyway I renew the tips given by other colleagues:

  • contralateral treatment
  • "total root treatment": do TENS starting from the spine until the end of the dermatome / nerve. You can also use different plugs along the path.
  • IFC in the sole, the portant current set it high as possible, over 2500Hz

Another TIP can be to change frequently the parameters during the treatment and session by session: frequency, intensity, voltage... you must modulate.

Thanks for your swift response. Pain is felt on deep palpation at the sole of the foot. However, tips from other colleagues on this platform were useful. Once again, thanks!

Ok, maybe this case is a typical case of "Egg-Chicken inversion" :D I mean...yes, the egg was been the injection, lead to the peripheral neuropathy (the chicken)... but the girl alterated her posture, for the pain, for neurological reasons (the chicken become the egg :D) ... and now probably, we have also and anatomical alternation (a new egg), a small plantar fascitis.

Try to restart, forget the injection, the neuropathy, treat the plantar fascia: LLLT, US, stretching, POSTURAL RIEDUCATION, Kinesiotape... maybe is another or a totally different problem, and only with IFC or TENS it will be a really LONG road...

This is beautiful, especially with the Egg-Chicken concept! However, my management were more of stretching techniques and postural re-education.

fisioniki289
fisioniki289

egbonfasuba264 said:

fisioniki289 said:

Have you tested the pain? I mean... is related to some functional or muscular test? May it be a trigger point activated? Soleus... plantaris...

Anyway I renew the tips given by other colleagues:

  • contralateral treatment
  • "total root treatment": do TENS starting from the spine until the end of the dermatome / nerve. You can also use different plugs along the path.
  • IFC in the sole, the portant current set it high as possible, over 2500Hz

Another TIP can be to change frequently the parameters during the treatment and session by session: frequency, intensity, voltage... you must modulate.

Thanks for your swift response. Pain is felt on deep palpation at the sole of the foot. However, tips from other colleagues on this platform were useful. Once again, thanks!

Ok, maybe this case is a typical case of "Egg-Chicken inversion" :D I mean...yes, the egg was been the injection, lead to the peripheral neuropathy (the chicken)... but the girl alterated her posture, for the pain, for neurological reasons (the chicken become the egg :D) ... and now probably, we have also and anatomical alternation (a new egg), a small plantar fascitis.

Try to restart, forget the injection, the neuropathy, treat the plantar fascia: LLLT, US, stretching, POSTURAL RIEDUCATION, Kinesiotape... maybe is another or a totally different problem, and only with IFC or TENS it will be a really LONG road...

egbonfasuba264
egbonfasuba264

fisioniki289 said:

Have you tested the pain? I mean... is related to some functional or muscular test? May it be a trigger point activated? Soleus... plantaris...

Anyway I renew the tips given by other colleagues:

  • contralateral treatment
  • "total root treatment": do TENS starting from the spine until the end of the dermatome / nerve. You can also use different plugs along the path.
  • IFC in the sole, the portant current set it high as possible, over 2500Hz

Another TIP can be to change frequently the parameters during the treatment and session by session: frequency, intensity, voltage... you must modulate.

Thanks for your swift response. Pain is felt on deep palpation at the sole of the foot. However, tips from other colleagues on this platform were useful. Once again, thanks!

fisioniki289
fisioniki289

Have you tested the pain? I mean... is related to some functional or muscular test? May it be a trigger point activated? Soleus... plantaris...

Anyway I renew the tips given by other colleagues:

  • contralateral treatment
  • "total root treatment": do TENS starting from the spine until the end of the dermatome / nerve. You can also use different plugs along the path.
  • IFC in the sole, the portant current set it high as possible, over 2500Hz

Another TIP can be to change frequently the parameters during the treatment and session by session: frequency, intensity, voltage... you must modulate.

egbonfasuba264
egbonfasuba264

Prof Oscar Ronzio said:

Hi, I recomend you to use also TENS in the contralateral lower limb.

Somers DL, Clemente FR. Transcutaneous electrical nerve stimulation for the management of neuropathic pain: the effects of frequency and electrode position on prevention of allodynia in a rat model of complex regional pain syndrome type II. Phys Ther.2006;86:698 –709

Prof Oscar Ronzio said:

Hi, I recomend you to use also TENS in the contralateral lower limb.

Somers DL, Clemente FR. Transcutaneous electrical nerve stimulation for the management of neuropathic pain: the effects of frequency and electrode position on prevention of allodynia in a rat model of complex regional pain syndrome type II. Phys Ther.2006;86:698 –709

Prof Oscar Ronzio said:

Hi, I recomend you to use also TENS in the contralateral lower limb.

Somers DL, Clemente FR. Transcutaneous electrical nerve stimulation for the management of neuropathic pain: the effects of frequency and electrode position on prevention of allodynia in a rat model of complex regional pain syndrome type II. Phys Ther.2006;86:698 –709

Prof Oscar Ronzio said:

Hi, I recomend you to use also TENS in the contralateral lower limb.

Somers DL, Clemente FR. Transcutaneous electrical nerve stimulation for the management of neuropathic pain: the effects of frequency and electrode position on prevention of allodynia in a rat model of complex regional pain syndrome type II. Phys Ther.2006;86:698 –709

Prof Oscar Ronzio said:

Hi, I recomend you to use also TENS in the contralateral lower limb.

Somers DL, Clemente FR. Transcutaneous electrical nerve stimulation for the management of neuropathic pain: the effects of frequency and electrode position on prevention of allodynia in a rat model of complex regional pain syndrome type II. Phys Ther.2006;86:698 –709

Prof Oscar Ronzio said:

Hi, I recomend you to use also TENS in the contralateral lower limb.

Somers DL, Clemente FR. Transcutaneous electrical nerve stimulation for the management of neuropathic pain: the effects of frequency and electrode position on prevention of allodynia in a rat model of complex regional pain syndrome type II. Phys Ther.2006;86:698 –709

I don't understand. Can you further explain pls?

egbonfasuba264
egbonfasuba264

wendy226 said:

Hi Fasuba As a practitioner, I have seen similar issues from injections and post hip replacements! As you say this is a peripheral neuropathy that would seem to have affected the common peroneal nerve on the antero-lateral aspect of the leg. But it has to have originated in the buttock/glute area where the injection was given. I would expect the slump test to be positive as you are stretching the whole of the sciatic nerve. I assume you have checked out the lumbar spine and sacro-iliacs - this is frequently the origin of pain in the leg/ foot when there is no direct injury to the leg/foot. Effectively this could be a neuropraxia, or even axonotmesis. My best advice would be to change the location of the TNS electrodes, or use Interferential to deal with the nerve damage (1 - 10Hz preferably). May I suggest one electrode on the L5 and one on the proximal fibular head. Maybe try for pain relief with the TNS first, but consider using the IFT to get the full recovery process underway. Hope that helps - Wendy

Thanks for time and recommendation!

egbonfasuba264
egbonfasuba264

Cliff Eaton said:

Hi Fasuba You never know what will walk through your door do you? You may find it difficult to get an answer to this one. Most of us are either practitioners or researchers As practitioners I cannot suggest a prescriptive intervention without having first independently assessed the patient My research colleagues may only be able to point you to clinical papers that have presented on similar cases You may be better, on this occassion, to seek an opinion from one of your peers, who can look at the child with you Best wishes Cliff

Thanks for your time and recommendation

Prof Oscar Ronzio
Prof Oscar Ronzio

Hi, I recomend you to use also TENS in the contralateral lower limb.

Somers DL, Clemente FR. Transcutaneous electrical nerve stimulation for the management of neuropathic pain: the effects of frequency and electrode position on prevention of allodynia in a rat model of complex regional pain syndrome type II. Phys Ther.2006;86:698 –709

wendy226
wendy226

Hi Fasuba As a practitioner, I have seen similar issues from injections and post hip replacements! As you say this is a peripheral neuropathy that would seem to have affected the common peroneal nerve on the antero-lateral aspect of the leg. But it has to have originated in the buttock/glute area where the injection was given. I would expect the slump test to be positive as you are stretching the whole of the sciatic nerve. I assume you have checked out the lumbar spine and sacro-iliacs - this is frequently the origin of pain in the leg/ foot when there is no direct injury to the leg/foot. Effectively this could be a neuropraxia, or even axonotmesis. My best advice would be to change the location of the TNS electrodes, or use Interferential to deal with the nerve damage (1 - 10Hz preferably). May I suggest one electrode on the L5 and one on the proximal fibular head. Maybe try for pain relief with the TNS first, but consider using the IFT to get the full recovery process underway. Hope that helps - Wendy

Cliff Eaton
Cliff Eaton

Hi Fasuba You never know what will walk through your door do you? You may find it difficult to get an answer to this one. Most of us are either practitioners or researchers As practitioners I cannot suggest a prescriptive intervention without having first independently assessed the patient My research colleagues may only be able to point you to clinical papers that have presented on similar cases You may be better, on this occassion, to seek an opinion from one of your peers, who can look at the child with you Best wishes Cliff

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