This case study outlines the diagnosis and treatment of a 57 year old woman presenting with throbbing pain in the right proximal lower leg. The client in question attended her initial assessment in May and is actively undergoing treatment for breast cancer. Her subjective assessment highlighted the following points;
- 2-3 year history of throbbing pain in the right shin
- Increased pain intensity in the last 3 months following the completion of chemotherapy for breast cancer.
- Occasional pins and needles into the right foot
- Worse at night
- Throbbing in the morning which eases slightly throughout the day
- Frequent sleep disturbance due to throbbing/aching in the shin
- No red flags: bladder or bowel incontinence, bilateral neurological symptoms or weakness, saddle anaesthesia
- History of lower back and neck issues which she has never received treatment for
- Has had an MRI of both the lower back and the right lower leg. Was told that there were no issues reported on either. Has not seen the reports.
Whilst receiving chemotherapy, she felt that the pain was easier to manage. But once her course of chemotherapy was completed, the pain returned with more intensity. She was re-referred through the NHS, having two MRI scans and an appointment with a physiotherapist who diagnosed a tibialis posterior strain.
The objective examination of the client’s lower limb aggravated no symptoms described in the subjective assessment. She had full active and passive range in both the knee and ankle, full strength and no pain through range or associated with loading. Palpation of the medial aspect of the gastrocnemius from the anterior view was reproductive of pain in the leg.
On assessment of her lower back, range was restricted throughout; although this could have been attributed to her chemotherapy. Discomfort in the lower back was provoked by active lumbar extension in standing. Further discomfort was reported as a result of a modified slump test. Initial testing of the client’s single leg raise in supine was negative, but when the right foot was plantarflexed and inverted; reproduction of the pain in the leg suggested a positive test favouring the peroneal nerve. On palpation of the lumbar vertebrae in sitting, vertebral levels L1 to S1 were stiff and sore, with L3-L5 provoking the most pain on central and right sided unilateral palpation.
Following this client’s assessment, a lumbar or lumbosacral radiculopathy with peroneal nerve involvement was diagnosed. Other than pain on palpation of the medial and anterior aspect of the gastrocnemius, there was no evidence to suggest a pathology of the musculature in the lower leg. We discussed the possible treatment options and how they could be modified for the client’s comfort. This client’s *oncologist had given permission for both acupuncture and electrotherapy to be used in a multi-modal approach to treatment*.
We agreed on a combination of treatments for the best possible outcomes, the treatment plan is as follows;
- Heat Therapy (Lumbar) 10mins in sitting**
- Lumbar Spinal Mobilisations
- Soft Tissue Massage
- Interferential Therapy
- Acupuncture
Home exercise programme :
- Lumbar Extensions from Prone Lying Position
- Lumbar Rotation Exercises from Supine Position
- Straight Leg Raise from Supine Position
Following her first treatment, she was advised to use heat on the lower back whilst at home and to complete the exercises above as instructed. We discussed the relevance of her MRI reports and the suggestion that she speak to her GP about accessing these was made. Patient expectations were discussed and an estimated timeline was given, taking into account the chronicity of her condition – therefore increasing the time taken for improvement.
She attended her second appointment four days later and reported that her quality of sleep had improved, with a significant reduction in the frequency of disturbance during the night. As expected, the pain in the medial lower leg was still present. At her third follow up appointment, the throbbing pain had resolved completely. A residual ache was still affecting the right leg, but pain intensity had reduced and was much more manageable. The client stated at this appointment that this was the first time in approximately two years that the throbbing pain had gone away. At the time of this session, the client had gained access to her MRI reports, with the results as follows;
Right Lower Leg MRI:
- Varicose Veins
Lumbar MRI:
- Minor degeneration of vertebral levels L3/4 and L4/5
- Right sided hemangioma*** @ L4/5 level causing compression of the L4/5 nerve root.
Based on the results of the MRIs, a discussion with the client concluded that her distal symptoms were likely being caused by the compression of the nerve root by the small hemangioma and that without intervention to remove this; the residual ache in the leg may be her new baseline. The client, although disappointed with the results and the lack of effective treatment received beforehand, was happy with her improvements so far and felt that she could function efficiently and manage the slight ache that she was left with. Following this appointment, myself and the client agreed to continue with maintenance type treatment, leaving one month between sessions to ensure symptoms do not worsen, under the pretence that she is able to come for treatment earlier if required. To date, this client has had nine sessions, the throbbing has not returned and her sleep quality remains improved.
A few main points to conclude:
- It is important for us as physiotherapists to listen to our clients and make our own diagnoses based on our own assessments. It would have been easy to accept the diagnosis of an ‘Advanced MSK Practitioner’ and continue treating this accordingly despite there being no improvement.
- Neurological symptoms are likely suggestive of nerve related issues – radicular pain or a radiculopathy from the spine.
- As physiotherapists, it can be tempting to accept the simplest of the differential diagnosis. Ensuring patient care is a main responsibility and we must complete thorough assessments and delve deeper than superficial, ‘easy to treat’ options.
- Muscular strains are highly unlikely to persist for 2-3 years.
*When treating a client who is actively being treated for cancer, permission is required from the oncologist in charge of their care to use methods such as acupuncture and electrotherapy due to the implications of increased circulation to the treated areas.
**The client was treated in sitting due to discomfort if required to lie in prone as a result of her breast cancer treatment – including lymph node removal.
***A benign tumour made up from a collection of blood vessels, they can be deep or superficial.
Are you suffering with sciatica? Don’t wait any longer, book an appointment now with one of our expert physio’s!
