Mr. X’s background
Mr. X, a 57-year-old moderate built Asian male, came to seek a solution to his 3 years not specific tingling sensation over both of his shin area. Mr. X fell and landed on his buttock three years ago. Since then he tried to be active to get better. He swam every day as told by one of the therapists. He was still working as a truck driver.
He has consulted various healthcare professionals including orthopedic doctors, chiropractors, physiotherapists, and bonesetters. His initial back pain was gone but there was still residual tingling sensation at both shins. He didn’t get full recovery and he wanted to get it sorted out.
The orthopedic doctor reported that it was not sciatica and MRI reported no slipped disc or any nerve root irritation or compression. He was diagnosed to have piriformis syndrome by another physiotherapist later on but the treatment did not make any progress.
Examination
Mr. X’s standing posture and movement were all quite good except that there were a few spinal segmental restrictions in the upper back area and junction between thorax and lumbar spine.
Neurodynamic tests and neurological tests were all negative. This excluded any nerve root impingement or irritation at the spinal level. However, his hip range of motion was not good with the left worse than the right. He said that he was asked to do intensive piriformis stretch to fix the “piriformis” syndrome. He had gone through a painful stage of overstretching and currently his range was reduced probably caused by scarring from inflammation.
With general listening assessment, there was tension at his dura somewhere near the base of his head, and arching revealed restriction at the left buttock area. Interestingly local listening exposed a strong restriction at his mesenteric root. Mechanical fascial mobilization in this area triggered his distal tingling sensation on both shins.
An interesting point I have to make here is that what kind of activities would make him worse. I guess you would probably ask this question at the beginning. The answer is lying on his front. He told me about it two to three treatment sessions later.
What did I do?
It was obvious that I had to do something at his mesenteric root to solve his complaints.
As a clinician, I would not just treat one thing at a time to prove I was correct in making a diagnosis. Instead, I did a lot of things on Mr. X’s body to get him better.
First of all, I loosened up his hips. I bet he has been stretching so hard on his hips and his piriformis muscle that there was scar tissue around his hip joints which stopped him from having a good internal rotation in neutral.
Regarding the mesenteric root, I had to use visceral manipulation to fix it.
Another thing that I did on him was his dura. His spinal cord was tight at the suboccipital area. Therefore I had to get it loosened up at the base of the skull, followed by at the sacrum region.
Even though his nervous system was not that restricted in terms of neurodynamic tests, I still mobilized his sciatic nerve with peroneal nerve bias. I also used soft tissue mobilization techniques to loosen up his tibialis anterior because they were tight. Most of the time it is very difficult for people to stretch that muscle.
Once everything softened up, I taught him how to do the core exercise to protect his back and to get the internal abdominal pressure even so that there would not be extra pressure acting on his guts which in turn press on his nerves.
Eleven sessions of treatment were done for over four months. His tingling sensation has diminished by 50%. Leaving behind will be his stretching exercise that will further reduce his scaring at his hips. He was expected to resume full sensation with time.
My thought
In the beginning, when I was evaluating Mr. X, I had the impression that it could be a cutaneous nerve issue — lateral sural cutaneous nerve [cutaneous innervation to the lateral side of the leg (origin L5-S2)]. However, the chances of getting bilateral problems like that were not common, unless it was from the spinal cord. Hence, my attention was driven to the core. There were a few things that prove my perception correct. First, Mr. X’s triggering factor was lying on his front. Second, the local listening and fascial restriction mobility test confirmed that there was a restriction around his lower abdominal area. Based on these I postulated that the source of the problem was from his lower abdominal area and when you look at what’s inside it, it will be the small intestine and the mesenteric root.
It is never sufficient to learn enough to treat a complicated case. The only way to achieve greatness is to keep learning different treatment methods and understanding human anatomy and physiology more.