Cutting or bleeding edge?

Hurricane Ike came and went, but it almost feels like he's still hanging around the Gulf Coast. The devastation was truly remarkable particularly for places like Galveston and the Bolivar Peninsula. If you've never been through a good sized hurricane, I wouldn't recommend it. My Alma mater, UTMB - Galveston, is finally getting back on its feet, seeing patients, and teaching PT students again. My thoughts are with them and any other folks devastated by this storm. We finally got the lights turned on and life is returning to normal, which for me means getting back to blogging on a more regular basis. The clinic has never been busier so there is definitely plenty to talk about.

For a self-proclaimed "ortho-guy" I certainly have been immersed in a great deal of neuroscience this year. I had a brief yet spirited set of interactions with the folks on SomaSimple, and currently enrolled in a class titled "Neurosciences in Orthopedics" at Texas Tech. I have to admit the study of neuroscience is really filling in a lot of gaps in my understanding of orthopedic conditions.

Neuroscience is creating some very novel therapeutic inventions. The paradigms of neuroscience are building on theories such as David Butler and Lorimer Moseley's work on pain as well as Michael Shacklock's neurodynamics. The exploration of neuroscience arises from an understanding that traditional orthopedic paradigms aren't always hitting the therapeutic bullseye. For example what explains the persistent symptoms of lateral epicondylalgia or anterior knee pain? These conditions often defy objective diagnositic testing and treatments based on the traditional tissue-healing inflammatory model. I would encourage anyone interested in learning more about these approaches to visit the sites listed above.

As with any treatment approach, I remain cautiously optimistic. As my father, a practicing family physician and medical veteran, often cautions me: It's good to be on the cutting edge, but avoid getting caught on the bleeding edge. New and different aren't synonymous with correct and irrefutable. We must continue to develop our understanding of human function without strictly adhering to old paradigms. At the same time, we must be prepared to embrace emerging theory without getting caught-up in the latest fad. At the end of the day, sound theory supported by strong evidence will continue to guide the best practitioners of this profession. I believe the field of neuroscience will meet the test of both theory and evidence and continue to provide salient answers.

One final note, I hope to make more regular contributions to my blog and appreciate everyone hanging in there with me. I'm in the midst of balancing my contributions to this blog with teaching, studying, treating, and recovering from coastal natural disasters! As this semester rolls on, I hope to contribute more regularly. Thanks and have a great weekend!

Calcaneal and Plantar Nerves: Overlooked contributors to heel pain syndromes?

So I'm sitting here in my living room watching coverage of the latest impending apocalypse (Hurricane Ike) churn in the Gulf. You might think it's an odd time for this Gulf Coast native to be thinking about heel pain, but here I am...thinking about heel pain. We can discuss the reasons I have no life at a later date.

Diagnoses seem to come in spurts in this clinic and I've recently been referred several cases of both infracalcaneal and retrocalcaneal heel pain. As with many of my treatment approaches, my tactics regarding heel pain have evolved considerably over the years. Despite this ongoing refinement, I still find heel pain to be both fascinating and frustrating clinical entity. For me, it is the LBP of the foot.

I recently did a literature search on the various incarnations of heel pain and was relieved to find I'm not the only one out there navigating through the fog. There are still gaping holes in our knowledge and understanding of this condition. In the midst of my literature search, one article stood out enough that I felt it worth mentioning.

Overview and Methods

The article was published in 2003 in the Journal of Foot and Ankle Surgery. The authors set out to determine if sensory abnormalities existed in the medial and lateral calcaneal nerve distribution in patients suffering from plantar heel pain. The study examined 97 feet in 82 patients reporting symptoms consistent with plantar fasciits including poststatic dyskinesia and tenderness to palpation along the medial calcalneal tubercle. Patients were excluded from the study if they had comorbidities such as radiculopathy or an equinus foot. Neurosensory testing was performed using a pressure-specified sensory device used to detect compression or entrapment of both large and small nerves.

Results and Conclusions

The authors found a significant number of patients with plantar heel pain display abnormal sensibility within the branches of the posterior tibial nerve. Abnormal sensibility was noted particularly within the medial calcaneal nerve (P<.0008) and lateral calcaneal nerve (P<.0001).

It is our belief that entrapment of the MCN plays an important role the development of plantar heel pain, and we were able to quantify abnormal sensibility in the cutaneous distribution of both the MCN and/or the MPN in a significant number of patients with plantar heel pain. The observed nerve dysfunction is most likely secondary to entrapment of the nerve trunk, or trunks, as a result of repetitive mechanical irritation. In response to this pathologic stimulus, we hypothesize that the injured nerve trunk undergoes in-continuity fiber disruption and intra- and perineural fibroplasia. Because 49.48% of our patients displayed abnormal sensibility in the cutaneous distribution of both the MCN and MPN, a proximal neural origin such as proximal tarsal tunnel entrapment of the PTN, or even lumbosacral radiculitis, plexopathy, or sciatic nerve impingement, should be considered in these patients.

Clinical Implications?

A treatment theme that seemed to resonate with me in this article was that of regional interdependence. For example, two of my patients with heel pain also have persistent lumbar pain - one with motor radiculopathy ipsilateral to the heel pain. These comorbidities may play more of a role in distal pathology than previously appreciated. Secondly, the findings of this article could lend support to the notion that neurodynamic movements such as lower extremity nerve gliding could play a role in more distal conditions such as heel pain. In addition to our traditional mechanically-based therapeutic regimen, it may make practical sense to consider structures such as the peripheral neural tree as possible contributors to the patient's problem.

Here's hoping all my neighbors along the Gulf Coast stay dry this weekend!

Rose JD, Malay DS, Sorrento DL (2003). Neurosensory Testing of the Medial Calcaneal and Medial Plantar Nerves in Patients With Plantar Heel Pain The Journal of Foot and Ankle Surgery, 42 (4), 173-177

Is Pain in the Brain?

I finally leaped into the 21st century and discovered I can post specific YouTube videos on my blog. This is an excellent lecture from the University of California on the origins of pain. Dr Basbaum is as sharp as they come on this topic and this is a very entertaining and informative lecture on pain science. I hope you are able to get something out of it!

Physical capacity and low back pain: Is there a connection?

We frequently advise patients that having strong trunk muscles and better lumbar mobility are important strategies to prevent future episodes of LBP. These types of recommendations go a long way to emphasizing autonomy versus dependence in managing this common musculoskeletal problem.

However, emerging evidence has spawned some serious questions and criticisms of our current paradigm regarding exercise and low back pain. For example, we still don't have a clear picture as to whether specific exercise programs or just activity in general is more effective at preventing LBP. We have even less specific guidelines regarding key exercise parameters such as volume or intensity of activity.

A recent systematic review in Pain raises even more difficult questions regarding the relationship between LBP and trunk strength, endurance, or mobility. After all inclusion criteria were met, the authors reviewed 24 articles. Relevant findings provided some very interesting food for thought.

• Trunk muscle strength and low back pain: Thirteen quality studies and four low-quality studies met the inclusion criteria and were reviewed. The authors found inconclusive evidence to support a specific relationship between trunk muscle strength and low back pain.

• Trunk muscle endurance and low back pain: Eight high quality studies and four low-quality studies were reviewed. In this case, there is strong evidence that there is no relationship between trunk muscle endurance and risk for LBP.

• Trunk mobility and low back pain: Seven high-quality studies and one low-quality study were reviewed. There was inconclusive evidence connecting lumbar mobility and low back pain due to conflicting results.

It should be acknowledged that there are some significant methodological limitations within this systematic review. There was substantial heterogeneity between many of the studies which should prompt the reader to cautiously interpret the results. However, as we are often keen to site evidence to support our interventions, we must all be prepared for the eventuality that our current paradigm may not be as rock-solid as we think.

Exercise will continue to be a significant part of my plans of care in the management of low-back pain. I doubt this will change dramatically, but systematic reviews like this have me looking even harder for the best available theoretical and clinical evidence to support my approach. Until next time!

H HAMBERGVANREENEN, G ARIENS, B BLATTER, W VANMECHELEN, P BONGERS (2007). A systematic review of the relation between physical capacity and future low back and neck/shoulder pain Pain, 130 (1-2), 93-107 DOI: 10.1016/j.pain.2006.11.004