Successful Osteopathic Manipulative Treatment of Foot Drop

Participants

• Number: 1

• Description: a 63-year-old man with weakness in his left foot for 5 years. The man had a history of hypertension, appendectomy and  right inguinal hernia surgery.
  In the past, the patient had done a lot of physical exercise, which including jogging and skiing.
  He had received some occasional massage and resorted to non-steroidal anti-inflammatory drugs when needed but had never sought any specific diagnosis or treatment as his foot weakness had not been of particular concern to him for a period of time.

However, the weakness had continued to worsen and pain had also appeared in the lumbar region, radiating down the left leg to the back of the foot. Eventually, the pain had become strong enough to hinder a variety of daily activities, reaching an intensity of 9 out of 10 associated with a constant weakness of the foot – a condition of foot drop – which led to limping.

As a consequence, the patient went for a neurosurgical consultation. The neurological examination showed intact cranial nerves, a motor strength of 5 out of 5 throughout the body except for a result of 4 out of 5 in left dorsiflexion and extensor hallucis longus. The sensory system was found to be intact to touch and proprioception with the exception of a decreased sensitivity in the first 3 toes of the left foot. In addition, deep tendon reflexes at the level of the left knee did not respond, and the patient had been unable to walk on his heels (but was able to walk on his toes). The MRI had revealed severe foraminal stenosis and lateral recesses at L4-5 level (aggravated by 1-cm spondylolisthesis of L4 on L5).

The diagnosis issued was of foot drop secondary to lumbar spinal stenosis. A decompressive laminectomy surgery had been advised to the patient both at the neurosurgical examination and at a subsequent orthopedic consultation,

Before proceeding to surgery, the patient wanted an osteopathic consultation. The evaluation found stable vital signs and a number of somatic dysfunctions: loss of dorsiflexion of the left foot, iliac crests of equal hight, motor strength of 4 out of 5 of the left hip in flexion and 2 out of 5 of the left foot in dorsiflexion. A hypertrophy of the lumbar paraspinal muscles was also found.
At this point, the patient accepted OMT.

Interventions and evaluations

• Osteopathic structural, motor strength, and symptom assessment.
• Evaluation by MRI at the end of the course of treatments.
• 1 initial OMT session, followed by 4 biweekly sessions and then a series of weekly sessions.
• OMT:
  • myofascial and muscle-energy techniques to relax thoracolumbar tissues and then high-velocity low-amplitude techniques in the thoracic, lumbar, and sacral areas.

Results

After the first treatment – in which there was a resounding click during the execution of a high-velocity low-amplitude technique in the lumbosacral region- the pain began to improve. After 4 more treatments, the patient noticed a clear improvement of his condition.

The physical examination, in fact, showed full recovery of motor strength (5 out of 5) of the left hip in flexion and of the left foot in dorsiflexion. The patient was also able to walk on his heels without much difficulty while the sensations in the left leg were also normal.

Following further OMT sessions, the patient no longer reported low back pain or foot drop.

The MRI carried out at the end of the treatment showed no difference from the first image.

Discussion

The OMT has been shown to be able to alleviate and resolve a foot drop condition secondary to changes in the spine, namely spinal stenosis and spondylolisthesis.

In fact, the MRI showed these changes at the level of the L5 vertebral segment, and in fact the nerve roots of L5 are normally the most affected in conditions such as lumbar radiculopathy with related foot drop. In cases of stenosis and spondylolisthesis, the nerve roots can become compressed and cause a range of sensorimotor symptoms, especially including pain, reduced range of motion, loss of strength, and foot drop.

Osteopathic techniques applied at the lumbar level (adjusted for the observed 1-cm spondylolisthesis) may have immediately favored an improvement in the patient’s condition because they induced a reduction in pressure on the nerve roots of L5. However, we must consider that the two MRIs showed no significant difference, a finding that may indicate another mechanism at work than the one just hypothesized. However, the two reports are difficult to compare because they were performed by different machines from different health care facilities.

Another possible mechanism underlying the patient’s condition could be a dysfunction (subluxation?) of the sacro-iliac joint, resulting in radicular symptoms. However, no specific tests were performed to verify the presence of this condition.