Case Study: Neurological issues and a good physical exam.

I often discuss the importance of carrying out a thorough physical assessment of my patients because so many issues go missed and badly (or un-) treated because their providers are not doing a thorough enough job. I have a case I'm working on right now that is a perfect example of that, and it’s lot less unusual than it looks like at first glance.

A 15 year old was referred to me for potential neurological issues who has had gait and general ambulation issues as long as the family can remember, with significant stiffness and pain issues through the posterior hips and legs. He did have a potential for some mild cerebral palsy and other neurological signs, but those were investigated and ruled out by his physicians.

Checking out his gait...yeah, it looks effortful and intentional, with something almost like foot drop on one side. His mother describes his running stride as very cramped, like he was just running with his lower legs. He did also have some notable vestibular findings (5' of forward movement in a 30 second fukuda test) and some challenges with the vestibulo-ocular reflex, saccades (they would get stuck in right fixation and would slow down as we kept them going), etc. He did have significant convergence issues in his past which he received therapy for and it now looks fantastic. So on the whole, there were some sensory issues, but not enough to cause severe gait issues, especially the ones he had (His static balance was actually quite good).

But when we checked him out for function and joint ROM, this is where it becomes beautifully mundane. Yeah, his lumbar and hip extension function was atrocious, he could not even internally rotate enough to check function of muscles like the pectineus and even his external rotators were iffy at best. His mother stated that he's never been able to even have his toes straight; they always severely externally rotate. Try to manually move them into internal rotation and yeah...not gonna happen. We try to passively flex the AF from relaxed supine and we had about 20* of flexion before he reported pain/threat and it had to stop. That's...not great.

Anytime you see a ROM the body doesn't want to do, think about what structures it would place tension on if the body were to allow that to happen. We lifted one leg and then the other into hip and knee flexion and he was HYPER mobile in internal rotation. So then we manually gave slack of the sciatic nerve towards the spine (outside of acute injuries, where it may get more complicated, nerves get relief by taking them towards the source. Well...kinda all vessels do, but that means arteries towards the oxygenated origin, veins and lymphatics towards peripheral origins, etc.) and we got his AF to more than 60* of flexion, and even in relaxed supine we could internally rotate those hips to a hypermobile range.

His other providers saw tightness and treated tightness, instead of seeing a body that was trying to protect something from being stretched. Muscular tightness is PROTECTIVE; it is a strategy to try to stop something from being stretched or loaded badly. We don't want to rip away that protective mechanism without giving anything back. He was prescribed aggressive stretching and rolfing and other very antithetical therapies to his situation.

So we're dealing with the why's of his sciatic restriction and irritation (which itself appears to be a fascinating case of repeated childhood spontaneous idiopathic eardrum ruptures). He was walking better at the end of his first session, the tightness is going away and he's not going to be stuck with this for his whole life.

He did have some vestibular issues to deal with because of the eardrum punctures, and there was a right temporo-occipital suture fixation that was really messing up some visual function, but mechanistically most of his issue was a nerve restriction and irritation.

Always ask why something is tight. What is it protecting? Don't just force it to let go. We can definitely still support the area manually by trying to calm down the irritated muscles, but it needs to be done gently, supporting it while we try to deal with why the brain felt that was a necessary response.

Don't just think muscles.