Reversing muscle contracture

[dibblego]

I had a severe superficial peroneal nerve injury/compression since an inversion sprain in July 2007. It was only recently figured out and I had decompression surgery in November 2009.

While I still have associated foot drop to some extent, the muscle contracture, which extends all the way up one side of my body (the side of the injury) is extremely uncomfortable. I do all kinds of stretches trying to reverse it, but I feel like I am making no progress.

Is there anything I can do to reverse it? Any tests to determine prognosis? Have I damaged my muscles? Thanks for any tips.

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[gcoe]

Hi Dibblego

I am just trying to get my head around your problem.

The contracture one usually gets from a peroneal nerve injury is contracture of the plantar flexors and invertors of the foot. This is due to the paralysis of the peroneus longus and brevis and tibialis anterior and extensor digitorim muscles.

If the injury was from an inversion sprain the most likely pathology was a traction injury of the superficial branch of the nerve that supplies peroneus longus and brevis muscles. If the injury to the nerve was truly a compression injury then it is more likely it happened well above the ankle and the sites of injury are usually as the nerve passes under peroneus longus or further up at the head of the fibula. In this case you may end up with the above problem plus a foot drop as well.

So...do you have:
1. a foot that turns in (towards the other foot knwon as inversion) and inability to activey turn the foot out?
2. a foot drop with loss of full movement lifting the foot and toes upwards? (known as dorsiflexion of the foot and extension of the toes)
3. clawing of the toes under the foot? - paralysis of the extensor digitorum

1, 2 or all 3?

As for discomfort running up the side of the body - this is not normally associated with a contracture or with a peroneal nerve injury - symptoms usually should not be above the knee. Could you have a causalgia or what is now referred to as complex regional pain syndrome II? This is a complication of nerve injury. Have a look at some literature on this and see if you think it might describe you:

http://www.rsds.org/pdf/recognizing_...ngCRPS_RSD.pdf

The symnptoms with CRPS are dramatic, severe and unignorable so I am not sure if that really describes you

A third option is that you have developed another chronic pain syndrome from your injury. All sorts of things can happen here. For example you may have develope myofascial pain - that is chronic pain that seems related to muscles which can become tender and can radiate pain up or down the body from the site of the muscle.

I think you need to get the diagnosis sorted out. It sounds like you have a bit more than just a nerve palsy. At this point you may want to go and see a pain specialist rather than a neurologist or neurosurgeon - someone who has expertise on ongoing pain problems.

I don't think I can really advise you on exercise or anything until you know more about this discomfort up the side of your body. As you have probably worked out yourself already. Nerve problems are complex and can result in changes to other parts of the nervous system - particularly to areas such as the pain processing system.

[dibblego]

Hello gcoe,
Thank you for the response. My problem was an trapped superficial peroneal nerve a few centimetres above the lateral malleolus. I have done all the diagnosing with respect to this injury, which is unfortunate. I cannot consult a specialist for a diagnosis because they have all (and I mean all) concluded that I am psychiatrically unstable and that I am "wasting others' time". This is despite the fact that I diagnosed it correctly and travelled interstate to have it successfully surgically treated. Even in light of the facts, they refuse to acknowledge the extent of their mistake (it extends well beyond just this one). I have visited a neurosurgeon who specialises in pain management, who told me that I am inventing the pathology because he had never heard of it in 40 years of practice. I have many stories like this and I am resigned to overwhelming medical incompetence in my state.

So all I have is the words of the treating surgeon who tells me it was a very nasty entrapment, and will take about 12 months to know the full outcome and it was precisely where I said it was (My essay pre-surgery in an effort to convince these fools was titled: The Case for Entrapment Neuropathy of the Superficial Peroneal Nerve 10cm Proximal to the Lateral Malleolus). My surgeon is also encouraged by my progress since surgery. Consider; I could barely walk on the day of surgery, and last week, I climbed a grade 4/5 mountain. I used to be a professional athlete before this injury.

My associated foot drop does not seem to align with what I have read in my orthopaedics text books (I own 23 of them now, yay!) and there is not much literature published on foot drop associated with SPN pathology, so I am tempted to suggest I have a partial foot drop. Immediately after surgery I was able to evert slightly (not at all before surgery).

My contracture symptoms have resulted in weakness in my gluteus and lower back muscles, all on the right-hand side. This causes difficulty breathing and restricts my muscle flexibility. My pelvis has turned on an angle as if tipping forward and my back muscles are extremely tight. These symptoms started at the time of the injury.

I read your leaflet and I don't think this sounds like me. I am not hyper-sensitive to pain, but my muscle problems do make me very uncomfortable. I really have the urge to put my foot into dorsiflexion in an effort to stretch muscles, but I simply can't and haven't been able to for a very long time (over two years). My intuition tells me that if I could just stretch these muscles I would have some relief, so I spend a lot of time trying, even though I know it is to no avail.

I have tried heel raises and various other efforts to get more strength into my foot muscles (MRI and NCS have determined denervation at EDB and EHB) for eversion, but I always feel like I am back to the same place.

I wish I could get a diagnosis, but I am certainly resigned to the fact that if I ever get one, it will be from my own investigations. The state of medical aptitude, at least in my area, is lamentable.

Thank you for your response.

[gcoe]

Hi dibblego

You certainly are knowledgeable about your problem and what you say on the whole makes sense to me. Thanks for filling me in on the details. I certainly don't own that many orthopaedic texts! - I'll know to consult with you on such matters in the future! :-)

It is unfortunate when the medical profession resorts to the relegating people to the "too hard basket" labelling them as psychiatric. This a wholly unhelpful cop-out thing to do but as you say is quite common.

From a functional/activity point of view you are doing very well getting back into mountaineering - sounds great!

However I am still a bit perplexed by this:

My contracture symptoms have resulted in weakness in my gluteus and lower back muscles, all on the right-hand side. This causes difficulty breathing and restricts my muscle flexibility. My pelvis has turned on an angle as if tipping forward and my back muscles are extremely tight. These symptoms started at the time of the injury.

People can have quite extreme reactions to the paralysis - maybe because you were walking around with such a poor gait after the injury you developed some compensatory motor control problems around the pelvic, spinal and thoracic segments. This doesn't sound like a chronic pain situation as such. rather a case of adaptive motor control that has got you into trouble. It surprises me these symptoms developed straight after the injury as often they develop more over time. However that doesn't rule out it being an adaptive problem.

Two suggestions:

1. you could seek an opinion from a PT that is skilled and experienced in movement impairment syndromes - this is an approach that looks at how poor habitual movement causes pathology. This approach can be affective in the overuse or chronic misuse kind of problem. Ask if your PT has skill in Dr Shirley Sahrmann's approach to movement impairment syndromes. Basically this is a balancing up the muscles approach - lengthening that which is tight, strengthening that which has developed length related weakness and avoiding bad motor patterns.

2. Another approach is a bit more out there on the borderlands of science. The Feldenkrais method and the Alexander method both are systems of movement education that may offer success with these sorts of problems, at least with some people. However the hard evidence is not always there. Of the two I would opt for the Feldenkrais method and visit a PT who is trained as a Feldenkrais practitioner as opposed to a Feldenkrais practitioner who isn't dually qualified. A Feldenkrais practitioner teaches in groups or individual lessons. The latter might be the best way. The experience is generally very gentle and involves by touch and movement making you aware of how you are using your pelvis, spine and ribs. A practitioner might be able to help you to work out what you are actually doing at a motor control level and give you options on how to move better. A sort of reprogramming the brain to work better. I trained in this method many years ago and although I don't use it a lot in my area of practice, I find it useful to fall back on when other things fail. Anecdotally I have had a lot of success with such adaptive problems when others have given up. As you seem quite aware of your body and the effect this is having on your functioning you may find this approach worth trying.

If you want some more info on either of these options let me know

[alophysio]

That is good advice gcoe.

Might i be so bold as to also suggest that in addition to having a movement impairment syndrome, he might also have overactivity in certain muscles - so not just lengthening the short muscles, shortening the long, strengthening the weak etc but also relaxing the overactive (no doubt global muscles) and increasing the activity of the underactive.

Otherwise i agree totally (for what it is worth!)

CHeers

[gcoe]

Yes that is a good point Alophysio. I think this is consistent with a motor control issue.

[dibblego]

Thank you for your replies. They have been very helpful. I intend to visit a physiotherapist to hopefully reverse this muscle problem.

One very obvious symptom that I should have mentioned is that the muscle between the bottom of my rib cage and top of my pelvis is so weak on my right side that the bones are nearly touching. The left side does not have this problem. My nerve injury was on my right lower extremity.

Thanks again for all your help.

[gcoe]

Hi Dibblego

Not quite sure what to make of that. I presume you are meaning the Quadratus Lumborum muscle but I wouldn't know for sure without seeing what it looks like. That muscle is innervated by t12 - L3 spinal nerves. This is way higher up than the part of the peripheral nervous system you damaged. Although it is all interconnected, it seems highly unlikely this would have been affected from an inversion injury to the ankle, no matter how severe. It is possible you have another diagnosis eg something damaged the spinal cord on that side - but that is just conjecture and it sounds like you had that all checked out.

One thing you could tell me - this isn't getting progressively worse is it? It sounds like it has plateaued out and if anything since the surgery you are a getting better.

Personally I think getting a fresh opinion from a clinician who can look at things holistically - someone who is prepared to spend some time looking into your presentation - is the way to go.

Let us know how you get on.

[dibblego]

Thanks for the response. I'm not sure which muscle(s); my anatomy knowledge is strictly to the lower extremity; My area of expertise is in formal logic and computer science

My problem is not getting worse, but has changed with respect to the severity of the nerve injury. These muscle problems have existed since a few days after the injury (July 2007) and my first (of six total) surgical procedure to the lower extremity in September 2008, which was an under-diagnosis, significantly worsened my neuropathic symptoms (I didn't know what it was at the time) and my muscular problems got considerably worse.

Since recent decompression surgery, there has been a slight improvement. The severity does seem to coincide with the amount of dorsiflexion/eversion I have. Prior to recent surgery I could barely put my foot on the ground let alone dorsiflex/evert it. Today I can get 0-1cm out from a vertical wall when I do a test with my foot flat on the ground with my knee touching the wall (does that test have a name?).

The comment about a movement pattern problem strikes my intuition as very plausible, but as usual I am compelled to seek out scientific literature to support the hypothesis.

Thanks again for all your input. You have been very helpful.

[gcoe]

The comment about a movement pattern problem strikes my intuition as very plausible, but as usual I am compelled to seek out scientific literature to support the hypothesis.

I couldn't agree more. However, I am sorry to say, as you have no doubt worked out, the science behind rehab is not exactly mature. If physics and cosmology is at the top food chain and biology might be somewhere around the developing herbivores then rehab science is floating somewhere between the amoeba and bacteria.

When it gets complex - as it seems to be in your case, then we don't have a huge amount to fall back on. One thing about the methods I have suggested, however is they are highly unlikely to cause you harm, even if it is a bit of a gamble on your part. You could be poorer but other than that you may have nothing to loose and everything to gain.

You might like to have a look at the lit. on the Feldenkrais method:

PEDro - Search Results

If you can retrieve the systematic review you'll need to speak German or get someone to translate for you

The Alexander Method has one very good trial for chronic low back pain:

Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain -- Little et al. 337: a884 -- BMJ

And here is one for Alexander method and Parkinson's Disease which is more my area of expertise:

PEDro - Detailed Search Results

I know I am throwing you evidence for conditions that are completely unrelated to yours. However given the paucity of research and also the unusualness of your presentation at least you may see that in a wide variety of chronic conditions that don't just get better by themselves and where it is plausable that there the nervous system's motor control has changed in response to impairments perhaps there are something in these methods.

At a more basic science level we do have more evidence for maladaptive changes motor control in a vast array musculoskeletal and neurological conditions. If you are interested I could try and hunt up a review article - but that might take a bit of time and effort.

[alophysio]

Hi - sorry but this is only a quick reply...

1. Consider Peter O'Sullivan's Article in 2005 i think in Manual Therapy about movement impariment disorders and the research that has continued since then if you are looking for scientific papers on movement disorders

2. Consider altered nerual pathways and central sensitisation and chronic pain changes to pain perception.

Cheers