This topic contains 4 replies, has 3 voices, and was last updated by 
Brandon Cohen DC, CSCS June 22, 2020 at 11:02 am.
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Brandon Cohen DC, CSCS
68F
Location: B. foot (plantar medial from heel to great toe, down to the 5th toe and then in the middle of the plantar foot back to the heel. Full dorsal aspect of the foot from the toes to the subtalar joint)
Quality: burning, paresthesia, stabbing
Intensity 6/10 most of the time, sometimes is 2/10
Palliative: none
Provocative: none2nd order: NCV impression: “evidence of bilateral S1 radiculopathy. There is no electrodiagnostic evidence of large fiber sensorimotor peripheral polyneuropathy. Recommendations: Imaging of the lumbar spine.
Symptoms went from no pain to current level of pain in about a day and a half. She had bloodwork done, which I have not seen. Reports it being “good.” She was told she does not have peripheral neuropathy and started taking gabapentin. This did not work, she started a new medication this week which also has not worked.
FastMap: Functional: 0 Structural: 0 M: 60 P: 30
I have not done an exam. I will evaluate her low back and check some ankle level material. My concerns are more that she has been to 4 different doctors who have been dismissive, and not very good.
What kind of doctor would you most reasonably refer her to?
William Brady, DC
Great case details. Most likely complex regional pain syndrome (reflex sympathetic dystrophy). The S1 nerve root NCV findings may be incidental or contributory. Check out: https://www.ninds.nih.gov/disorders/patient-caregiver-education/fact-sheets/complex-regional-pain-syndrome-fact-sheet
Add some of the diagnostic criteria to your ID exam.
There is some speculation that sympathetic entrapment can cause/contribute to this condition. See more about that anatomy here: https://www.ncbi.nlm.nih.gov/books/NBK539914/ Yes, they even perform a sympatheticectomy for CRPS!
At an insanely high palpatory level I would palpate the sympathetic chain adjacent to the psoas and feel for mobility and reproduction of complaint. Do not do this unless you are confident in your skills.
We are getting ahead of ourselves. Confirm the blood work. Do the exam and report back.
Thanks
Brandon Cohen DC, CSCS
Okay, after reading, CPRS is most frequently caused by trauma, but this is not always the case.
I’m working on getting eyes on the bloodwork. I’ll have to go through her PMH a little more and get more details. Patient is overweight and doesn’t sleep well. Previously been diagnosed with pre-diabetes, so I’ll need an update on that status.For the exam, I’m planning on level material for the low back and lower extremity. I will also rely heavily on palpation and see how we can provoke the symptoms. I will likely do a LE neuro exam.
Are there any other history questions I should consider asking her that might clear some of this up?
If I’m unable to elicit anything, where might I send her? Most of the options in the reading didn’t look too great.
What else might I want to include in the exam? Would we expect the neuro exam to add good information?
Thanks!
Keith Puri, DC
Another DDX to consider is small-fiber polyneuropathy (SFPN). SFPN is less known but is a common cause of neuropathy. NVC studies only assess for large nerve disorders. Small fiber neuropathies will have a negative NVC, diagnosis is most often made through a skin biopsy.
What is SFPN?
https://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/peripheral_nerve/conditions/small_fiber_sensory_neuropathy.Video on SFPN
https://www.radcliffe.harvard.edu/video/anne-louise-oaklander-small-fibers-big-pain-new-research-fibromyalgia-and-small-fiberBlood work for SFPN
https://neuropathycommons.org/neuropathy/tests-causes-neuropathySkin Biopsy for SFPN
https://neuropathycommons.org/neuropathy/skin-biopsyIn-office exam for SFPN
https://www.researchgate.net/publication/325948713_Validity_of_Clinical_Small_Fiber_Sensory_Testing_to_Detect_Small_Nerve_Fiber_Degeneration/link/5bbcc122299bf1049b7851ce/download
Brandon Cohen DC, CSCS
Still waiting on bloodwork.
I did an exam last week. It was very complicated. The patient is so metabolically strained that she could not lay on her back long enough to do both SLR and SHF due to SOB.
Here are some of the findings from the exam:
DF: 68%L (limited by knee flexion, no pain but knee stops range) 86%R posterior leg stretch B.
QLF: 70%
KHE: 8″R 12″L mild anterior thigh stretch B.
PK (modified due to knee flexion): 1/2″ B. with no sx.
Lockout: weak bilaterally
PKF, PKE, KFHE, lunge not performed.I asked and checked for the following, none of which were present:
change in skin texture or sweating
abnormal nail or hair growth patterns
Abnormal movement patterns
Stiffness in jointsI also palpated through the plantar foot while patient was sidelying, and palpated the hip flexors and sympathetic chain.
B. Medial plantar nerve 2
L. Flexor digitorum Brevis 2
R. Psoas 2
L. Psoas 1
I do not currently possess the skills to palpate past the psoas in this patient due to my skill or the obesity of the patient. I could barely get into the superficial fibers to the psoas.I’m still waiting on bloodwork, and don’t have a diagnosis post exam. Nothing of what I found seems to warrant any treatment at this time until she gets so many other things under better control I hope there’s a smoking gun in those labs.
After I saw her for the consult and requested information from the primary care they called her to get the blood work ordered. It was as if they didn’t take her seriously or just forgot.
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