Management of Tibial Neuropathy in a 61-Year-Old Male Patient

Background:

Meet a resilient 61-year-old male who approached us with persistent calf stiffness and sporadic mild numbness lasting for about a year. Despite previous consultations and prescribed medications yielding limited results, a referral from a satisfied patient at AMBULANT PHYSIOTHERAPY brought him to our care. Remarkably, he had no prior history of pain or underlying medical conditions. This is such a rare condition that isn’t seen very much In the clinical setting without significant history.

Presenting Symptoms:

Upon examination, the patient described a loss of sensation at the bottom of his foot, accompanied by a mild burning sensation. Additionally, he noted a mild impairment in toe flexion and extension, which he attributed to his habitual use of work boots or trainers.

Assessment:

Our initial focus was on evaluating the patient's lower extremities, with attention to the foot region. Concerns included apparent loss of sensation and diminished toe mobility. The examination revealed a history of baker cyst, potentially compressing the tibial nerve and causing sciatic nerve compression at the popliteal fossa level. Further examinations ruled out similar conditions, such as tarsal tunnel syndrome, lumbar radiculopathy, and plantar fasciitis. A positive Tinel sign was noted, along with mild strength changes in the gastrocnemius, poor Achilles reflex, and slight overpronation of the foot.

*non-diabetic and no signs of infection and no h/of any trauma.

Treatment Plan:

Our physiotherapy approach aimed to address tibial nerve palsy and enhance overall lower limb function. Key strategies included:

1. Neurological Assessment: Detailed assessments to pinpoint the exact location and extent of tibial nerve involvement, with tibial nerve flossing to release tension and compression.

2. Manual Therapy: Soft tissue mobilisation techniques to reduce calf stiffness and enhance blood flow. Gentle massage and myofascial release alleviated muscle tension.

3. Sensory Re-education: Exercises to help the patient regain sensation in affected areas, including sensory discrimination drills.

4. Motor Re-education: Incorporation of exercises to address mild loss of toe flexion and extension, improving muscle strength and coordination.

5. Custom Orthotics: Recommendation of custom orthotic insoles to provide support, alleviate pressure on the tibial nerve, and enhance overall foot biomechanics.

6. Patient Education: Education on footwear choices, regular stretching, and proper foot hygiene to prevent future complications.

7. Progress Monitoring: Close monitoring of the patient's progress through regular follow-up appointments, with adjustments to the treatment plan as needed.

Outcome:

Remarkably, the patient's recovery from tibial nerve palsy showed significant improvement through sensory and motor re-education exercises, manual therapy, and custom orthotics. The patient's commitment to treatment and adoption of appropriate footwear choices underscored the importance of comprehensive physiotherapy in achieving positive outcomes.

?For extensive reading about tibial neuropathy and similar foot neuropathies which have the same symptoms please refer to the following.

Torres AL, Ferreira MC. Study of the anatomy of the tibial nerve and its branches in the distal medial leg.?Acta Ortop Bras.?2012;20(3):157-64.?[PMC free article] [PubMed]

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Singh G, Kumar VP. Neuroanatomical basis for the tarsal tunnel syndrome.?Foot Ankle Int.?2012 Jun;33(6):513-8.?[PubMed]

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Nitz AJ, Dobner JJ, Kersey D. Nerve injury and grades II and III ankle sprains.?Am J Sports Med.?1985 May-Jun;13(3):177-82.?[PubMed]

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Kuran B, Aydo? T, Er?al?k C, Arda P, Y?lmaz F, Do?u B, ?ncü J, Durlan?k G. Medial calcaneal neuropathy: A rare cause of prolonged heel pain.?Agri.?2017 Jan;29(1):43-46.?[PubMed]

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Bruce BG, Bariteau JT, Evangelista PE, Arcuri D, Sandusky M, DiGiovanni CW. The effect of medial and lateral calcaneal osteotomies on the tarsal tunnel.?Foot Ankle Int.?2014 Apr;35(4):383-8.?[PubMed]