Shin pain is a relatively common complaint among runners, with typical treatments including activity modification and therapeutic rehabilitation. Neurodynamics is a treatment that can modulate pain through the central and peripheral nervous systems. A positive neurodynamic test may indicate a dysfunction in the mechanical interface and should prompt the clinician to consider neurodynamic treatment. We present the case of a division I track and field athlete with shin pain who was treated successfully using peroneal sliders in combination with traditional rehabilitation exercises.
A 20-year-old female collegiate pole-vaulter reported at the end of indoor track season complaining of bilateral pain in her shins. She rated her pain as 5 out of 10 on the Numeric Pain Rating Scale (NPRS). The patient reported a recurrent history of shin pain every spring for the past 3 years with the start of the outdoor track season that resolved only with rest over the summer. Previous treatments included anterior strengthening exercises and posterior stretches commonly used to target medial tibial stress syndrome (MTSS). On initial evaluation of the current episode by the athletic trainer, the patient was point tender along the anterior tibialis, peroneus brevis, soleus, and posterior tibialis muscles. She also had tenderness to palpation along the middle third of the posteromedial tibia. There was no tenderness to palpation along any of the other bony structures of the lower leg, ankle, or foot. The patient displayed full and equal knee and ankle range of motion bilaterally, but noted having pain along the anterior tibialis and toe extensor tendons with plantarflexion. Results of special tests (the calcaneal bump test and the lower leg compression squeeze test) were negative. No neurological symptoms were present and no imaging was performed for this patient.
The patient was initially instructed in the performance of rehabilitation exercises focusing on anterior strengthening and posterior stretching in addition to daily ice massages, a typical regimen performed as part of the care of MTSS. She had no limitations in her sport other than participation to tolerance. The patient did not take any nonsteroidal anti-inflammatory drugs (NSAIDs) during the course of her treatment. Following the first week of treatment, the patient reported a reduction in pain of the left leg to 3 out of 10 on the NPRS with no change for the right leg. The patient reported that she felt she had stopped making improvements in her pain.
At this time, the Patient-Specific Functional Scale (PSFS) and the Disablement in the Physically Active Scale (DPA) were administered, with the patient scoring 6.33 and 21, respectively. The DPA is a measure designed to assess patient-reported pain and disability, with an average score of 3.7 in a healthy population.1 The PSFS asks patients to identify and rate activities based on difficulty of performance, from unable to perform to pre-injury ability.2 Although normative values have not been established in a healthy population, the minimal clinically important difference for the PSFS is 2 to 3 points.2
On day 8, neurodynamic peroneal sliders3 were added to the patient's rehabilitation (no changes were made to the other therapeutic exercises). The peroneal sliders were performed with the patient in a slumped position as she held her foot in plantarflexion and inversion while performing knee flexion and extension (Figure 1).3 The sliding technique was performed slowly and gently, ensuring that the patient did not experience an increase in symptoms. The patient and clinician maintained constant dialogue throughout the treatment to ensure that the patient was using appropriate technique. In addition to performing the peroneal sliders in the athletic training clinic, the patient was also instructed to perform 2 × 10 repetitions before going to bed at night. After two days of treatment that included the peroneal sliders, the patient reported 0 out of 10 pain bilaterally on the NPRS.
Example of peroneal slider with (A) knee extension and (B) knee flexion.
The patient was discharged from treatment 12 days after initial evaluation. She had an NPRS score of 0, a DPA score of 0, and a PSFS score of 10 (Table 1). The patient remained symptom-free at the 3-month follow-up visit and was able to participate without limitations in her sport. The patient reported that she had used the sliders on occasion (ie, two to three times over the 3 months) but had stopped performing them as part of her daily routine.
Results of Patient Outcomes Measured During Course of Treatment
Up to 44% of runners suffer from MTSS symptoms.4 Conservative treatment of MTSS typically includes rest, ice, therapeutic exercise, and activity modification.5 The efficacy of traditional treatment for MTSS is inconclusive. Some researchers have found that calf stretching in addition to orthotic use is an effective way to reduce shin pain on the NPRS.6 Other researchers have identified that calf stretching and strengthening in addition to activity modification is no more effective than activity modification alone.7
Neurodynamics is an emerging technique used to treat musculoskeletal pain and dysfunction with neural system involvement. The technique is designed to restore optimal functioning of the mechanical interface between neural and non-neural structures.8–10 The mechanical interface includes any structures (eg, muscle or fascia) that make up the nerve bed.10 Neurodynamic treatments focus on rectifying the dysfunction present in the mechanical interface by modulating pain through the central nervous system and enhancing communication between the involved structures.10 To discern between neural involvement and musculoskeletal response, differentiating movements must be performed.10
Dysfunction of the neural system related to movement sensitivity is termed neuropathodynamics.11 As the body moves, the musculoskeletal and nervous systems work in concert to promote normal, fluid motion. The nerves become naturally sensitized by the mechanical stress involved with movement.10 For this patient, nerve irritation may have occurred if the nerve was compressed by the contraction of nearby muscles.10 Because the current case patient displayed neural involvement (eg, positive specific neural movement tests), neurodynamic treatment with sliders or tensioners was indicated. Both techniques involve simultaneous movement of both ends of the nerve, with the ends moving in either the same (sliders) or opposite (tensioners) directions.12 Sliders were chosen over tensioners because they are less likely to evoke symptoms and are thought to reduce pain and sensitivity while promoting healing.10
Current research on neurodynamics has focused primarily on upper extremity or sciatic nerve treatments.13 Sciatic sliders have been used to increase range of motion in individuals with apparent hamstring tightness.14 For treatment of the lower leg, only one case study was found that included the use of neurodynamic sciatic sliders in the successful treatment of peroneal nerve paralysis and lower limb muscle weakness.15 The current case study is unique in that it provides evidence for the inclusion of peroneal sliders in the treatment of medial tibial stress syndrome, a syndrome with a paucity of research supporting efficacy of treatments.
Implications for Clinical Practice
Best practices for treating MTSS are inconclusive given the current literature, ranging from orthotics and calf stretching6 to activity modification.7 The use of neurodynamics, specifically the peroneal slider, may provide an alternative or adjunctive method to successfully treat MTSS by restoring a functional interface between the musculoskeletal and neural systems.8–10 Incorporating neurodynamic peroneal sliders into traditional rehabilitation approaches may promote long-term resolution of MTSS symptoms, as demonstrated in this case review.
Traditional methods of treating MTSS are varied in both type and effectiveness of treatment. There is currently no literature considering the efficacy of including neurodynamics in the treatment plan for MTSS. Despite this, neural sliders have been demonstrated to be effective in the treatment of some musculoskeletal conditions, especially in the upper extremity and hamstrings. The case review presented is the first to suggest the utility of considering neuropathodynamics as a potential cause of lower leg pain (MTSS) and peroneal sliders in the treatment of patients with positive results on neuromovement examination who present with MTSS. It is possible that the patient in this case was suffering from peroneal nerve entrapment in addition to symptoms of MTSS. Future research must be conducted to assess the use of neurodynamic sliders in the treatment of lower leg pain without signs of possible peroneal nerve entrapment.
- Vela LI, Denegar CR. The Disablement in the Physically Active scale, part II: the psychometric properties of an outcomes scale for musculoskeletal injuries. J Athl Train. 2010;45:630–641. doi:10.4085/1062-6050-45.6.630 [CrossRef]
- Horn KK, Jennings S, Richardson G, Vliet DV, Hefford C, Abbott JH. The patient-specific functional scale: psychometrics, clinimetrics, and application as a clinical outcome measure. J Orthop Sports Phys Ther. 2012;42:30–42. doi:10.2519/jospt.2012.3727 [CrossRef]
- Butler DS, ed. The Neurodynamic Techniques: A Definitive Guide from the Noigroup Team. Adelaide, Australia: Noigroup Publications; 2005.
- Yagi S, Muneta T, Sekiya I. Incidence and risk factors for medial tibial stress syndrome and tibial stress fracture in high school runners. Knee Surg Sports Traumatol Arthrosc. 2013;21:556–563. doi:10.1007/s00167-012-2160-x [CrossRef]
- Galbraith RM, Lavallee ME. Medial tibial stress syndrome: conservative treatment options. Curr Rev Musculoskelet Med. 2009;2:127–133. doi:10.1007/s12178-009-9055-6 [CrossRef]
- Loudon JK, Dolphino MR. Use of foot orthoses and calf stretching for individuals with medial tibial stress syndrome. Foot Ankle Spec. 2010;3:15–20. doi:10.1177/1938640009355659 [CrossRef]
- Moen MH, Holtslag L, Bakker E, et al. The treatment of medial tibial stress syndrome in athletes: a randomized clinical trial. Sports Med Arthrosc Rehab Ther Technol. 2012;4:12. doi:10.1186/1758-2555-4-12 [CrossRef]
- Butler DS. The Sensitive Nervous System. Adelaide, Australia: Noigroup Publications; 2000.
- Nee RJ, Butler D. Management of peripheral neuropathic pain: Integrating neurobiology, neurodynamics, and clinical evidence. Phys Ther Sport. 2006;7:36–49. doi:10.1016/j.ptsp.2005.10.002 [CrossRef]
- Shacklock M. Clinical Neurodynamics: A New System of Musculoskeletal Treatment. Philadelphia: Elsevier Health Sciences; 2005.
- Mhatre BS, Singh YL, Tembhekar JY, Mehta A. Which is the better method to improve “perceived hamstrings tightness”—exercises targeting neural tissue mobility or exercises targeting hamstrings muscle extensibility?Int J Osteopath Med. 2013;16:153–162. doi:10.1016/j.ijosm.2013.06.002 [CrossRef]
- Coppieters MW, Butler DS. Do “sliders” slide and “tensioners” tension? An analysis of neurodynamic techniques and considerations regarding their application. Man Ther. 2008;13:213–221. doi:10.1016/j.math.2006.12.008 [CrossRef]
- Ellis RF, Hing WA. Neural mobilization: a systematic review of randomized controlled trials with an analysis of therapeutic efficacy. J Man Manip Ther. 2008;16:8–22. doi:10.1179/106698108790818594 [CrossRef]
- Castellote-Caballero Y, Valenza MC, Puentedura EJ, Fernández-de-Las-Penas C, Alburquerque-Sendín F. Immediate effects of neurodynamic sliding versus muscle stretching on hamstring flexibility in subjects with short hamstring syndrome. J Sports Med. 2014;2014:127471. doi:10.1155/2014/127471 [CrossRef]
- Villafane JH, Pillastrini P, Borboni A. Manual therapy and neurodynamic mobilization in a patient with peroneal nerve paralysis: a case report. J Chiropr Med. 2013;12:176–181. doi:10.1016/j.jcm.2013.10.007 [CrossRef]
Results of Patient Outcomes Measured During Course of Treatmenta
|MEASURE||INITIAL EVALUATION||DAY 7||DAY 10||DAY 12||3-MONTH FOLLOW-UP|
|Average NPRS||5/10 bilateral||3/10 left; 5/10 right||0/10 bilateral||0/10 bilateral||0/10 bilateral|