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Manual Therapy
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Case report
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 18 November 2010
Received in revised form
8 February 2011
Accepted 9 February 2011
Exercise-related lower limb pain represents one of the most common presentations in sports medicine
practice. This is usually caused by musculoskeletal overuse injuries but not uncommonly, a neuropathic
cause may be suspected. A review of the literature revealed that peripheral neuropathic pain has never been
documented in a child. It is possible that peripheral neuropathic pain of spinal origin may be more prevalent
in children than previously recognized. This case report describes the presentation of a 12 year old tennis
player with bilateral dorsal foot pain, who presented with positive ndings of peripheral nerve sensitization
which was successfully managed using neurodynamic treatment techniques. Differential diagnoses are
considered and treatment and management described. A discussion of the clinical reasoning which led to
the patients diagnosis is included. This case report suggests the effectiveness of neurodynamic treatment in
a child with bilateral foot pain who fullled published criteria for peripheral nerve sensitization. However,
the single case methodology employed in this study limits generalization of its ndings. Further studies are
warranted to investigate the role of neurodynamics in musculoskeletal pain disorders in children.
2011 Elsevier Ltd. All rights reserved.
Keywords:
Peripheral neuropathic pain
Neurodynamic treatment
Neural tissue mechanosensitivity
1. Introduction
Exercise-related lower limb pain represents one of the most
common presentations in sports medicine practice (McCrory et al.,
2002). This is usually caused by musculoskeletal overuse injuries
but not uncommonly, a neuropathic cause may be suspected (Gallant,
1998; McCrory et al., 2002). In addition to compressive radiculopathy
and nerve entrapment, peripheral neuropathic pain mechanisms may
contribute to musculoskeletal syndromes commonly seen in sport
such as hamstring strains (Kornberg and Lew, 1989) and ankle
inversion sprains (Pahor and Toppenberg, 1996).
Various examination procedures have been proposed to assist
with the diagnosis of peripheral neuropathic pain (Elvey and Hall,
1997; Shacklock, 2005; Nee and Butler, 2006). Such disorders
have been recently sub-categorized (Schafer et al., 2009a, 2009b)
into sensory hypersensitivity (involving predominantly sensitization of the central nervous system), denervation (due to signicant
fascicular damage) and peripheral nerve sensitization (arising from
increased axonal mechanosensitivity). Elvey and Hall (1997) presented a series of physical examination criteria required to be
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Table 1
Summary of outcome measures on rst and last physiotherapy sessions.
Outcome measure
Session 1
Session 17
8/10
Pain-free
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Table 2
Description of treatment.
Session
Session 1 (day 1)
Intervention
Patient evaluation and data collection
Patient educatione clinical diagnosis
e postural correction in sitting
e postures/activities to avoid
e tennis training sessions reduced to 3 times weekly (9 h)
Neural mobilization e supine with towel roll under lumbar spine, right SLR with
plantarexion/inversion to just prior to pain provocation (5 sets of 20 repetitions)
Neural mobilization e as previous session
Home exercise program e supine, right hip held at 90 exion, active right knee extension with
plantarexion/inversion to just prior to symptom reproduction (2 sets of 20 repetitions twice daily)
Neural mobilization e as previous session except increased to 5 sets of 30 repetitions
Home exercise program esecond home exercise added, extension in standing (10 repetitions) intermittently
during day to break up prolonged sitting
Neural mobilization e supine with towel roll under lumbar spine, left SLR with plantarexion/inversion
to just prior to pain provocation (5 sets of 20 repetitions)
L2 left unilateral PA mobilizations (grade III) in prone with left leg positioned just prior to pain provocation,
in SLR with mid range plantarexion(6 sets of 1 min)
L2 left unilateral PA mobilizations as previous session except grade III
Patient educatione tennis training sessions increased to 4 times weekly (13 h)
L2 left unilateral PA mobilizations as previous session except foot positioned in end range plantarexion
Patient educatione tennis training increased to full weekly schedule (15 h)
e stop right neural mobilization home exercise
e continue extension in standing exercise to break up prolonged sitting
e future back care
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