We like to say that Chiropractors are doctors of the nervous system. That is, we care for and nurture the brain and spinal cord and can also support many other aspects of nervous system health. So it should come as no surprise that neuropathy falls under this generous heading. Neuropathy (sometimes known as peripheral neuropathy) occurs when there is damage or entrapment of nerves outside of the brain and spinal cord. While the particular nerve and its location bear great significance for how this neuropathy will express itself, one thing is for sure: it’s no fun.
While chiropractic care is often focused on vertebral subluxations, it is also true that extremity adjusting and other specific techniques can target specific peripheral neuropathies (not to mention that adjusting the spine can often have a direct or indirect impact on them). But how might this work on an individual level? A recent case report has taken aim at a less common neuropathy: that of the sural nerve.
The sural nerve runs through the gastrocnemius muscles and along the lower leg, providing innervation to parts of the lower third of the leg and the foot. It originates from branches of the tibial and fibular nerves, with input from the S1 nerve root level and L5 level (in the lower back).
Nerve entrapments are caused by compression or irritation of nerves in narrow anatomical spaces. This may be the result of repetitive motions, prolonged movements, or injury. Commonly, symptoms include persistent pain, burning and aching sensations, or numbness in the areas the nerves are responsible for. If entrapments persist without appropriate management, an individual’s quality of life can be severely impacted, contributing to anxiety, depression, and sleep difficulties.
So as you can see, it’s something that shouldn’t be ignored.
In a recently published case report, a 36-year-old Canadian male veteran was referred to a Pain and Wellness Centre for a consultation. He had experienced calf tightness ten years prior, which had gradually resolved without intervention. After a time, though, the tightness returned and interfered with some motions and exercises required in his occupancy, specifically jumping, marching, and running. Following physiotherapy, the tightness eased but would frequently return after episodes of activity and interfere with performing his normal duties.
Diagnostic imaging taken during this time was unremarkable, after which he sought orthopedic, sports medicine and interventional consultation. It was concluded that the patient was experiencing left-sided mid-substance Achilles tendinosis. He then received corticosteroid injections, prolotherapy and tendon scraping, with minimal pain relief.
Enter chiropractic care:
When the patient presented at the Pain and Wellness Centre, the pain was described as intermittent searing and burning calf pain. The patient noted that the pain worsened with movement and improved with rest, scoring a 54/70 on the Pain Interference Scale of the Brief Pain Inventory. This indicates a high degree of pain-related functional interference. Additionally, the patient scored a 22/27 on the Patient Health Questionnaire-9 questionnaire and an 18/21 on the Generalised Anxiety Disorder-7 questionnaire, indicating the patient was experiencing both severe depression and anxiety.
A thorough Chiropractic evaluation was conducted, resulting in the diagnosis of chronic left-sided sural neuropathy secondary to entrapment within the gastrocnemius fascia. He was also diagnosed with Major Depressive Disorder and Generalised Anxiety Disorder. The diagnosis was rendered by the pain physician based on the chiropractic evaluation and questionnaire scores. The patient was admitted to the Pain and Wellness Centre’s government-funded Interdisciplinary Pain Program, providing 80-90 hours of one-on-one treatment across multiple disciplines at no cost to the patient.
While he received a ‘whole person approach’ to treatment, this case report predominantly focuses on Chiropractic intervention. Psychological treatment, mindfulness training, and massage therapy were all received by the patient through the program. The patient attended 11 in-person chiropractic visits and 13 sessions by phone to accommodate the significant distance he had to travel. These chiropractic visits were usually an hour long, consisting of “variable combinations of manual therapy, physical rehabilitation, strength and conditioning…” .
The long-term goals of care were to reduce pain and allow the patient to run for 30 to 45 minutes, at moderate exertion, three times a week. Cupping was performed over the suspected sural nerve entrapment site during five of the 11 in-person sessions. Otherwise, they were focused on active care. Phone sessions were dedicated to goal setting, education, and problem-solving.
While the initial case report is more detailed in protocols and includes images of Sural nerve sliding mobilization among others, it is encouraging to note that the course of care coincided with gradual, steady improvement in his pain and functioning across the board.
The patient concluded his care through the program and, at that time, was able to run two to three times weekly for 20 minutes and reported a complete resolution of left calf pain. There was also a complete resolution of sensory alteration. At the 6- and 12-month follow-ups, the patient reported a continuation of pain-free running. There was also a substantial improvement across emotional and mental health aspects, overall rating himself as ‘very much improved’ on the Patient Global Impression of Change Scale.
This case report is well worth the wander over to the Journal of the Canadian Chiropractic Association for full details. Not only that, it paints a picture of how a person’s whole picture of health can be impacted by neuropathy, and how the impact of chiropractic can reach well beyond pain alone. The normal case report limitations apply, but we are happy to see another case in which a person’s function has returned, and their mental and emotional health and quality of life has lifted as their pain has resolved.
- Abbas A, Assimakopoulos D, Mailis A. Diagnosis and conservative management of sural neuropathy: a case report. J Can Chiropr Assoc. 2023;67(1).