Download Sacroiliac subluxation following ankle sprain mimicking sciatica

Sacroiliac subluxation following ankle sprain mimicking sciatica
Lateral ankle sprain (LAS), also referred to as inversion sprain, is the most common
injury in sport, with residual symptoms present in many patients (1,2). Disturbed
neurological function is often seen following LAS, including impaired proprioception
and sensation (2,3,4). Additionally, direct involvement of neural tissues, including injury
to peroneal and tibial nerves, has been observed following LAS (5). Because an intact
afferent nervous system is important in providing the feedback necessary for effective
motor control, LAS may influence afferent feedback affecting stability and muscle
function, both locally and regionally in the lower extremity (2,5). Altered muscle
function has been shown to both activate and perpetuate myofascial trigger points
(MTrPs) that can result in local and referred pain (6,7). Gluteus maximus MTrPs
typically demonstrate pain referral patterns that include the sacroiliac joint, buttock
region and proximal aspect of the posterior thigh, and sacroiliac joint dysfunction often
occurs along with the soft tissue dysfunction (8). Sacroiliac syndrome is likely in some
cases to produce pain, numbness or paresthesias above the knee or nonradicular referral
below the knee (9).
Case Report
A 52-year-old right handed male presented with complaints of right-sided low back and
hip pain with paresthesia in the right leg and foot. The patient denied knowledge of any
precipitating event, stating that the pain came on gradually approximately six months
prior. He described the pain as being a constant dull ache in the right sacroiliac, gluteal
and hip areas that radiated into the right posterior and lateral thigh and posterolateral calf.
He rated the pain as being 8 out of 10 currently, with average 8 out of 10 and worst 10
out of 10. He stated that the pain was worse with standing, walking and sitting and was
relieved by applying ice to the right buttock and supine hook-lying. The patient had been
recreationally active as a hiker and highly accomplished martial artist, and he stated that
he had been unable to engage in those activities for the prior two months because of the
pain. He stated that this condition had been previously diagnosed by a medical doctor and
a chiropractor as sciatica. Treatments had included anti-inflammatory medication,
physical therapy, massage therapy and chiropractic care. The result was temporary relief,
but not resolution of the symptoms. The patient stated that his goal in seeking care was a
pain free return to functional activities.
Past medical history was significant for severe right LAS approximately fifteen years
prior, which was treated with anti-inflammatory medication, ice and rest.
Physical examination included gait and posture assessment with the following findings:
an antalgic gait favoring his right side, a right anterior innominate with a left pelvic
upslip, externally rotated right lower extremity with calcaneal valgus, bilaterally
protracted shoulders with right sided upward rotation and winging of the scapula and
anterior head and neck carriage with right lateral flexion. Muscle atrophy was noted in
the right gluteus maximus muscle. Upon palpation the patient reported point tenderness
along the right posterior iliac crest, PSIS, right lateral sacral border, greater trochanter
and sacrotuberous and sacrospinous ligaments. Palpation along the gluteal musculature
resulted in a reproduction of the patient symptoms of pain in the right sacroiliac, gluteal
and hip regions that referred along the posterior and lateral thigh to the calf. Active range
of motion (AROM) was within normal limits for the lumbar spine, hip and ankle except
as noted in degrees: lumbar flexion 30 with pain, right hip internal rotation 20 with pain,
right hip external rotation 30 with pain, right hip extension 10 with pain, right ankle
dorsiflexion 10. Passive range of motion (PROM) assessment revealed reduced right hip
flexion, external rotation and ankle dorsiflexion with early muscle spasm end-feel.
Manual muscle testing for the right hip was graded as follows: flexion 5/5, extension 3/5,
external rotation 4/5, internal rotation 4/5, adduction 5/5, abduction 3/5; manual muscle
testing for the left hip and knee and ankle bilaterally were all within normal limits.
Straight Leg Raise Test produced sacroiliac and gluteal pain at 45 degrees, Millgram’s
Test was positive for sacroiliac and gluteal pain. FABER Patrick Test was positive for
pain in right gluteal region. Resisted straight leg raise in supine and prone positions
resulted in right sacroiliac pain that was relieved by trunk flexion with ipsilateral rotation
and contralateral shoulder extension and internal rotation, respectively. Prone hip
extension and side lying hip abduction movement patterns were altered including reduced
firing of right gluteus maximus and minimus and synergistic dominance of lumbar spinal
erectors and hamstrings and tensor fascia lata, respectively. Navicular Drop Test results
were 8 millimeters on the left and 11 millimeters on the right. Results for timed single leg
balance were as follows: left leg eyes open 30 seconds, eyes closed 15 seconds; right leg
eyes open 13 seconds, eyes closed 6 seconds. Squat test revealed decreased motor control
of pronation at the right foot-ankle complex, right knee adduction and left lateral weight
shift. Slump Test with plantar flexion and inversion (PFI) was positive on the right for
paresthesia in the lateral leg and foot. Dermatomes, myotomes and deep tendon reflexes
were with normal limits bilaterally. Radiological studies were not performed.
Diagnostic impression
Our findings indicated the patient suffered from right sacroiliac subluxation, gluteal
MTrPs and adverse neural tension of the superficial peroneal nerve secondary to LAS.
Passive management included chiropractic adjustment to the right sacroiliac joint,
neuromuscular therapy (NMT) and postisometric relaxation (PIR) to the right gluteal
musculature and Grade II-III joint and neurodynamic mobilization to the right fibular
head and superficial peroneal nerve, respectively, twice weekly for three weeks. The
patient was fitted for functional orthotics for control of excessive foot pronation.
Immediate active care included instruction in neutral spine posture and abdominal
hollowing maneuver (AHM) in supine hook-lying and prone quadruped positions and
biofoam roller self myofascial release for the leg, thigh and gluteal regions. Closed chain
foot adduction exercises were initiated to activate the right tibialis posterior and
functionally control foot and ankle pronation (11).
Case Management Outcomes
After four weeks of care examination revealed increased AROM and PROM at the
lumbar spine and hip joints without pain. The patient was provided with balance sandals,
the use of which has been shown to significantly impact the degree and timing of muscle
activation in the gluteal and leg musculature (10,11), and directed to walk forward,
backward and side-to-side three times per day for five minutes each. One week later the
patient reported that the average pain was 1 out of 10 with the worst being 3 out of 10
and notably less frequent. The patient stated that he no longer had pain or paresthesia
below the knee. Examination revealed normal, pain free AROM and PROM in the
lumbar spine, right hip and right ankle joints. All special tests were within normal limits.
The patient was given a program of neuromuscular autostretching for the
gastrocnemius/soleus, hamstrings, hip adductors, hip flexors and rotators and erector
spinae, as well as spinal stabilization exercises including prone, supine and side lying
floor bridges and alternation arm and leg reaches in the quadruped position. The patient
returned to martial arts training five weeks after the initial visit and reported only slight
discomfort in the right gluteal and posterior thigh regions. The patient was discharged
from care after progressing satisfactorily in his exercise program after week eight.
Figure 1. Visual Analog Scale (VAS) for Pain
The patient reported a significant decrease in pain levels after 5 weeks of care
10
9
8
7
6
5
4
3
2
1
0
Average pain
Worst pain
Wk 0
Wk 4
Wk 5
Discussion
This case study demonstrates the importance of a thorough examination of the kinetic
chain
to
determine
precipitating
and
perpetuating
factors
in
idiopathic
neuromusculoskeletal pain. In this case, LAS incurred fifteen years prior resulting in two
separate pathologies not uncommon in such injuries. Altered leg vibration sense, balance
deficits and inhibition of gluteus maximus has been demonstrated subsequent to LAS,
possibly due to altered joint proprioception and sensation (2-4). Inhibition and altered
muscle activation are frequently seen in conjunction with MTrPs (6,7). Activation of
MTrPs in gluteal musculature is often seen in activities requiring forceful and repetitive
hip extension and abduction, common motions in martial arts kicks. Sacroiliac
subluxation, as well as MTrPs can demonstrate pain referral patterns that include the
sacroiliac joint, buttock region and proximal aspect of the posterior thigh, not unlike that
distribution of pain in cases of sciatic neuritis. Sacroiliac joint dysfunction often occurs
along with the soft tissue dysfunction (8). Gluteus minimus and medius MTrPs are often
associated with MTrps in gluteus maximus and pain referral patterns include gluteal,
posterior thigh and calf and lateral leg regions (11). The gluteus maximus has been
shown to be an important component of the force-closure mechanism component of the
SI locking mechanism (12). It is postulated that in this case that the inhibition of gluteus
maximus secondary to the LAS resulted in MRrP activation associated with the patient’s
sport and recreation activities (SRA) of martial arts and hiking, with secondary activation
of MTrPs in gluteus minimus and medius. Concurrently, right sacroiliac dysfunction was
precipitated secondary to abnormal biomechanical stress applied to the joint due to the
muscular dysfunction and altered arthokinetic reflex (13). These dysfunctions were
perpetuated by the kinetic chain effects of excessive foot and ankle pronation (14-16).
This patient also demonstrated adverse neural tension in the superficial peroneal nerve
secondary to the LAS. While the cause of such dysfunction has not been conclusively
established, it has been postulated that scarring secondary to nerve traction injury would
result in adhesions that could restrict the ability of the connective tissue coverings to
elongate during functional movements that apply a stretch to the neural structure. While
nerve trunks are highly resistant to stretching because of their connective tissue
coverings, scarring could result in a tethering of the connective tissue and result in tensile
stress being applied to the axon, resulting in motor and sensory impairments (5,17). The
superficial peroneal nerve is susceptible to stretching with the position of knee extension,
plantar flexion and inversion, and if the ability of the nerve to elongate with such
movements is compromised pain and paresthesia could result. Certain martial arts
stances, as well as hiking on uneven terrain, place the lower extremity in positions that
can stretch the superficial peroneal nerve. Under normal conditions where the connective
tissue coverings are free to glide and elongate, pathological stretching of the nerve does
not result. In this case, however, it is proposed that scarring of the connective tissue
covering secondary to LAS resulted in adverse neural tension being applied to the
superficial peroneal nerve resulting in the patient’s neurological symptoms in the lateral
leg and foot.
Conclusion
This case presentation details the favorable outcome of a patient with local and regional
sensorimotor dysfunction and associated symptoms secondary to LAS. The use of an
integrated, management model involving chiropractic adjustments, joint and soft tissue
mobilization combined with therapeutic exercise resulted in the return of this patient to
high-level functional activities within eight weeks. Clinicians must be aware of the
kinetic chain implications of neuromusculoskeletal injury and direct treatment plans to
address local, regional and global dysfunction.
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