Issues with legs, neuro or vascular, not sure!

[robertharper216]

Hello,

Firstly a word of warning, this is quite a long post, mainly due to the fact that it is an ongoing issue and that I have been trying various lines of treatment. Although I have received good treatment, I feel like I have exhausted some outlets and think that getting fresh ideas would be sensible. Furthermore there may be people on here who have had similar symptoms or know of a patient who has. Any advice would be hugely appreciated.

History;

The problem first started around 2 years ago and apart from the Achilles issue(which I shall mention later) it has not changed a huge amount in that time.

I am in the Military, in an active role(as a paratrooper) and have been in this role since I was 16, so about 9 years. In that time I have done a lot of running, weighted marches and general fitness. I would say I am in good shape, I am 180cm tall, 13 Stone and run a half marathon in about 1:20. I began cycling about 3 years ago and began competing in road cycling events within a year. Symptoms began to present about a year after I took up cycling although it is potentially unrelated.

I first went to the physio due to numbness in my toes and cramping/flushing sensation in my calfs when cycling. To be more specific I would lose all sensation in my toes about an hour after beginning cycling. I also started to notice a flushing sensation in my calfs and cramping. The cramping was definitely not related to a nutritional deficiency as my diet is good and I have always been vigilant with hydration and electrolyte levels during exercise. I tried a series of flossing exercises but the conditions remained the same.

Approximately 4 months later I started to notice that the higher intensity I trained at, the more likely it was that cramps would occur, for instance, a hard row followed immediately by a run. I also started to notice the flushing sensation after long drives in the car, successive days on the bike and prolonged seated periods. At its worst I would cramp after a long drive, The flushing sensation would increase until an actual bite point where the cramp would occur.

The latest thing to go was my achilles, standard tendonitis and although I cant prove it, I imagine it is related. At the same time I developed a dull ache in my back, worse when seated for prolonged periods but again may or may not be related.

Treatment:

• Initially poor flexibility was addressed, it could still be improved hugely
• Flossing was attempted but unsuccessful
• Due to the symptoms always being symmetrical on both legs the physio thought it was my back so I had an MRI which showed;
  
  • A stable but old pars defect, potential from cricket as a youngster
  • A small step in one of my vertebrae but again no action required

Due to the back being clear the physio did not prescribe anything and instead I am doing my own plan to attempt to address the problem. I am doing;

• General flexibilty
• Lumbar mobility
• Eccentric calf raises
• Flossing

I would like to try and pinpoint the problem and address it head on. I stumbled upon a paper about numb feet and referred low back pain caused by very tight calf muscles. I have extremely tight calfs and hamstrings. Is this a possibility, should it be my first port of call?

I will hammer out 2 hours of physio exercises a day if necessary, especially to get back on the bike in winter without numb feet. Any help would be great

Thanks Rob

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[physiobob]

Hi Robert, thanks for the post. I have to say right now it feels like perhaps unrelated pieces might have been put together to to form a jigsaw diagnosis, which is not unreasonable. By that I mean there might be one or two things going one which are indirectly related but not necessarily claudication even at a mild level. A vascular insufficiency could give these symptoms and a 'flushing' sensation would be felt as the blood flow is restored to normal.

I cycle a lot myself and found I developed a numb left foot for a long time. In fact it has been really hard to work that one out despite looking intensively as the foot, lower leg and low back. Thing thing that in fact helped the most was a new par of shoes with more room and some arch supports inside them. This in fact really helped gain more strength during the push on the cranks.

Now that may or may not be involved. The pars defect and bilateral nature of your symptoms is an interesting one. It is very common in young bowlers and can result in intermittent, ongoing annoyance. A defect could indicate that you have an unstable segment which tends towards a small Spondylolisthesis. Now that might only be symptomatic after a period of loaded flexion, such as rowing or cycling. Once you become upright things pinch for a time and then return to normal. It would be a good idea to perhaps mimic a routine and see if you can provoke the symptoms in clinic and then your local physio can do more assessment.

You could also provoke symptoms and then get a plain x-ray in flexion to see if there is any malalignment at that time. The problem with supine MRI's it that the spine is loaded and if things are mobile they should return to a resting position during the scan.

Another thing to check is the pedal pulses in the foot/ankle area when the numbness if there and compare to when things are normal. This could also be done in the clinic if you can provoke symptoms at that time. In general if it is a mechanical cause then 'hammering' out physio in the beginning is not really the concept. Working on core stabilisation, movement correction and improving fatigue resistance will all help and it sounds like you are doing some of that already.

Perhaps if you can consistently provoke the symptoms then you can let us know a pattern and the pattern and timing of the symptomatic behaviour during that process, e.g. what gets numb first, any areas of pain, right side vs left side etc. I am sure others will have ideas so this is a nice place to discuss.

One last point that I might mention is that i did see a fighter pilot for a long time following numbness in the feet pulling a several G turn. It seems like blood flow but eventually we nailed it down to the harness he was wearing and possible the seat of the plane. I say this also as if you are regularly jumping you will have both pulling on your harness on your pelvis and well as some forceful loads as you land. That could easily cause a milalignment of the pelvic bones and disruption to the normal tone of muclses in the buttocks, e,g. piriformis. An insufficiency there could well lead to symptoms like those you are experiencing as well. So ask the physio to assess your pelvic symmetry as well.

Look forward to other peoples input.