Case 2: S1 Radiculopathy Flashcards
Radiculopathy rec time and activity management.
- Symptoms easing within 1-2 weeks
- Fully resolved usually within 4-6 weeks
- For some people, the symptoms can stay around longer as nerves are very sensitive structures.
- Good outcomes are expected with physiotherapy management.
- It can take some time for the condition to settle and it isn’t something to be concerned about, but if you do experience a drastic increase in your symptoms, consult me or a doctor immediately.
What is Radiculopathy?
- Radiculopathy is irritation to a nerve as it leaves your spine, causing the symptoms you are experiencing.
- Radiculopathy can be traced down the affected nerve, for example, the femoral nerve that runs down your buttocks, thigh, and into the bottom of the foot is the one being impacted.
What can the patient do?
- It is important to let symptoms settle, so let’s work together to identify what activities are causing the irritation and temporarily limit these activities in order to help your symptoms settle
- Modifications at work – get patient to help identify these (hours, change of position, task modifications, regular breaks and movement)
- Continue some exercise and keeping up a normal routine
- Can start taking short walks and slowly increase walking time and distance
- Will start getting you performing more exercises as your symptoms permit
- Might be helpful to consult GP for appropriate pain medication to assist with short term symptom management
Ax priorities of Radiculopathy:
- Observational + Functional ax
- Fixing of Lateral Shift
- AROM + Repeated repetitions
- Neurological
- Neurodynamic
- Manual Exam (Palp + PAIVMS)
Ax Observational + Functional Tests/results
- Evident LS to the left
- Sit to stand - Pain, reduced pain after correction of Lateral Shift
Ax Correction of Lateral Shift:
- Lateral shift correction:
- This will likely to be uncomfortable and painful but the majority of the time it only takes a few reps to correct the shift
- Lateral shifts can contribute to LBP, so it is important that we correct it and can see if that was the aggravating factor
- Patient stands with side that the shift is occurring to against wall with elbow on
wall (or arm by side). Opposite hand on hip - Gently leans hips towards the wall, holds for a few seconds and then returns
preferably only back to midline. - Likely to be uncomfortable – continue if centralisation of symptoms are
occurring and increased ROM/reduction of shift (after 5-10 reps) - Reassess regularly – observation and ROM – the patient can self-observe in the mirror
Ax AROM + Repeated repetitions Tests/results
Flexion - pain down leg and back, 1cm past patella
Lateral flexion and rotation normal
Extension - pain and decreased ROM
Repeated Ext - reduced pain and increased range
Ax Neurological Tests/results
3 Parts:
- Motor
- Sensory
- Reflexs
Motor:
S1/2 standing single leg calf raise
L1: Iliopsoas
L2: Quads, inner range
L3: Tib ant
L4: Extensor Hallicus Longus
L5: Extensor Digitorum Longus
L5/S1: Peroneals
L5/S1: Toe Flexors
L5/S1/S2: Hamstrings
Sensory:
- Eyes closed - checking normal
- 2 times light touch, each side, compare (Assesses dorsal/posterior columns and spinothalamic tracts)
- If any differences on light touch, rate the differences (out of ten), perform pinprick (Assesses
spinothalamic tracts) and map area.
L1: Groin/upper medial thigh
L2: Middle Medial thigh
L3: Medial knee
L4: anterior medial shin and medial foot
L5: dorsum of foot and toes
S1: lateral border of foot
S2: medial heel (note – in some people S2 is not medial heel – if suspected –
sensation test the medial posterior leg)
Reflexes:
L3/4 - Knee
S1/S2 - Achilles
Ax Neurodynamic Test
3 parts
- PNF
- SLR
- PKB
- Passive neck flexion
- Pat in supine, no pillow under head or knees
- Move neck in and out of neck flexion
- Opens up cervical canal and lumbosacral nerve moves cranially
- Expect slight stretch on upper cervical but no pain - Straight leg raise
- Pat in supine, no pillow under head or neck
- Move patients leg into hip flexion ensuring keeping knee straight
- Expect 50-120 degrees
- Pulling or stretch sensation in the posterior
thigh, the back of the knee and the posterior calf.
- Tests sciatic nerve
- Sensitising maneuvers: - DF
If ankle DF increases thigh or back symptoms in SLR then the neural tissue is implicated - IR
The sacral plexus is tightened when the hip is medially rotated. - ADD
Hip adduction also places stress on the lumbosacral plexus due to its pathway - PF + IN
This movement when performed prior to SLR or added at the end of the SLR test is designed
to move and tension the peroneal nerve more. The typical response is a stretching pain in
the anterolateral leg, ankle and foot that may spread to the knee, posterior thigh or calf. This
test is quite useful in testing for neural involvement in patients with lateral ankle or knee
pain or pain in the anterolateral leg region. - Prone Knee Bend
- Pat sidelying
- Bend knee
- Tests L2, L3 or L4 nerve roots which are the components of the femoral nerve.
- Normal symptoms are confined to the anterior and anterolateral thigh, mainly in the middle
one-third.
- The sensitising manouver to differentiate femoral nerve and rectus femoris:
Ask patient to lift head to see if symptoms reduce (reduced tension on neural system)
Ax Manual Exam (Palp + PAIVMS) tests/results
Patient unable to get prone- therefore must do Side Lying
Palpation: Tenderness R buttock and R posterior thigh
Flexion PPIVMs = Normal, no symptoms
Lateral Flexion PPIVMs = L = R, no symptoms
PAIVMs (modified in side lying)
↓ L4 – 1/10 back pain
↓ L5 – reactive++ and reproduced back pain (VAS 4/10)
L4/5 and L5-S1 R unilateral PAs - also reactive (VAS 4/10 in back)
Tx priorities of Pat:
- Advice and Education
- Correction of Lateral Shift is not done in Ax
- Reduce Pain
- Initiate exercise to decrease pain and increase belief/confidence
Tx - Advice + Education
- From your PE, I believe you have a condition called Radiculopathy at the S1 level of your vertebrae.
- Radiculopathy is the irritation of a nerve at the level it leaves the spinal column, which is causing your symptoms.
- In most cases, we see symptoms beginning to ease within 1-2 weeks with a full recovery within 4-6 weeks. Some times symptoms stay around for longer, just as nerves are very sensitive structures
- You have very favourable outcomes with this condition, as you have come in straight away we can work together to try and reduce the pain and modify some of your activities in the short term to help you continue your life as best as possible
Tx - Reduce Pain
- Sleeping positioning:
It is important that we try to reduce the compression placed when we sleep so a good technique is to have your impacted side up ie Right.
We can place a pillow between your legs and sleep in side-lying as this will help keep your back in a neutral/comfortable position - Work modifications
It is extremely important that you remain working, It has been shown that majority of the time, staying at work and modifying your work load and activities has far more favourable outcomes then having time off work
A few options we could do is:
1. Talk to your boss about potentially working more of an administrative role in the short term to allow more frequent sitting and reduce your required prolonged standing all day that aggravates your pain
2. Have regular breaks, this could include changing positions frequently, ie sitting and standing
3. Avoid positions that replicate symptoms and put the nerve on stretch
4. Potentially working shorter shifts - Keeping active:
It is very important that you continue your normal routine, just with some modifications for the short term. We can shorten the length of walks, break them into 2 a day. Take up swimming or cycling that reduce the load on the nerve - Addressing any concerns that the patient may have – eg need for surgery – give indications for referral on but de-threaten this as a likely scenario.
Tx Initiate exercise to reduce pain and increase confidence in movement
Flexion preferenced positions:
- Supine knees side to side
- knees to chest
- 4 pt kneel cat camel. Consider progressions of these in the short term.
- Shorter walks, pool walking/hydrotherapy
- Include education about acceptable pain/symptom levels during and after exercise – eg 3- 4/10 Lx pain is OK during HEP but should avoid exacerbation of leg pain/symptoms
