Clinical Red Flags in the Diagnosis of a Patient with Atypical Lower Limb Pain-A Case Report

MOJ Orthopedics & Rheumatology

Abstract Case Report

Background and purpose: When a patient’s signs and symptoms do not promptly point to a plausible cause of pain or dysfunction, it is important to think about Volume 6 Issue 2 - 2016

and differential diagnostic process for a patient with atypical bilateral lower limb paina differential due to a benigndiagnosis. thoracic This spinalcase report tumor. describes the clinical decision-making 1Mt. Eden Physical Therapy Center, USA Case description: 2Department of Physical Therapy & Rehabilitation Science, University of California San Francisco, USA followed by left kneeThe pain patientand weakness, had a right sixteen-month hip and low insidious back pain, onset as well and as poorprogressive balance aggravationand gait abnormalities. of a bilateral, non-specific foot pain and tingling, *Corresponding author: Jean Pierre L Viel, Mt. Eden

Outcomes: Following surgical resection of a thoracic schwannoma and three months of rehabilitation, patient recovered completely. Physical Therapy Center, 19845 Lake Chabot Road, Suite 205, Received:Castro Valley, August CA 94546, 10, 2016 USA, | Published: Email: October 20, 2016 Discussion: This case demonstrates the need for physical therapists to judiciously listen to patients’ complaints, even when these do not make sense objectively, and perform a complete neurological examination whenever bilateral limb symptoms are reported, even as common as foot pain.

Introduction progressive symptoms. This case report describes a patient with progressive lower limb pain and sensory impairments, which As the development toward direct access to physical therapy eventually revealed themselves as neurologic sequelae caused services grows, it is important for physical therapists to recognize by a focally asymptomatic, benign, and rare tumor of the spine: a patients’ symptoms appropriately, especially when these are thoracic intradural and extra medullary Schwannoma. atypical, and make immediate referrals for further testing when necessary [1]. The main objective of a physical therapy evaluation Schwannomas are benign tumors originating from Schwann is to determine whether intervention is appropriate, whether cells. Schwann cells are a variety of neuroglia that primarily consultation with another healthcare provider is needed, or provide myelin insulation to axons in the peripheral nervous whether the patient needs to be seen by another practitioner system of vertebrates [6]. They are the peripheral nervous system’s [2]. The patient’s description of symptoms and the therapist’s analogues of the central nervous system oligodendrocytes. assessment of objective signs should make sense, be based on the Spinal intradural extra medullary tumors account for two therapist’s knowledge of basic and clinical sciences, and on the thirds of all intra spinal neoplasms and are mainly represented clinical experience of the therapist. If the symptoms and clinical by meningiomas and schwannomas, with the latter accounting signs are atypical, the therapist should suspect an etiology which could potentially be serious, such as infection, visceral disease, or Most often benign tumors such as schwannomas do not cause malignancy. neurologicalfor 60 to 75 sequelae. percent Intradural of all primary spinal intratumors spinal account tumors for only [7]. As an example, spinal tumors will occasionally cause a small proportion of central nervous system tumors, with an compressive atypical neurological symptoms [3], mimicking incidence of 0.3 per 100,000 per year. Presenting symptoms are those of multiple sclerosis or common musculoskeletal symptoms varied [8]. They are typically slowly progressive, with or without back pain, and may mimic the results of neurological disorders problems frequently referred to physical therapists for treatment. such as multiple sclerosis, lumbar radiculopathy, peripheral such as plantar foot pain, quadricipital insufficiency, or sciatica -- neuropathies, or upper motor neuron lesions. The incidence of common symptoms and signs are shown in (Table 1). for approximately 30 percent of primary intra spinal neoplasms, Tumors like schwannomas and neurofibromas, which account The purpose of this case report is to describe the process of important for physical therapists to be able to make a distinction making a differential diagnosis for a patient with atypical lower between[4-5] can “classic” produce musculoskeletal such atypical neurologicalsymptoms, and symptoms. atypical ones It is limb pain and weakness. for which the clinical presentation is usually the delayed onset of

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Table 1: Clinical symptoms and signs, on initial examination, of extra medullary and intra medullary spinal tumors [10].

Extra Medullary Tumors (n=76) Intra Medullary Tumors (n=39) (Prcentage of Cases) (Percentage of Cases)

Pain (Local or Radicular) -63% -49%

SensoryLimb DisturbanceStiffness -39% -54%

Limb Weakness -20% -36%

-53% -41%

Sphincter Disturbance -20% -10% Weakness

Spasticity -55% -69%

-29% -23%

Sensory Disturbance -36% -36% Case Description fasciitis”. Another physical therapist initially saw this patient, approximately 6 months after the onset of her foot Patient description pain. B. Examination: Pain. This patient’s chief complaint was largeThe retail patient store. was Her a healthy medical and history fit 46 was year-old unremarkable, woman (165 except cm, for67 kg)a right who ankle was sprain employed about as a year full-time before sign she coordinator was referred for to a weekbilateral as a foot result pain, of foot worse pain, in and the her morning, walking rated tolerance as 5-6/10 was our clinic. Her case was chosen because over 16 months she on a visual analog scale (VAS). She woke up 4-5 times a presented with an array of symptoms in her lower limbs and her back that were misleading to her caretakers. It was not until her Her45 to medications 60 minutes. at She the reported time included that her Vioxx feet (Merck“felt swollen”, & Co., symptoms changed dramatically that their etiology was revealed. and that her left knee felt “inflamed” when she walked. Her condition did not prevent her from working or function at hormonal supplement. home, but it affected her quality of life and altered her sleep. She Inc.) once-a-day, which she was taking as directed, and a had no children and was generally healthy. She was referred for C. Posture/observation: The patient’s standing posture physical therapy to address bilateral foot pain. Her goals were to observed from the anterior, lateral and posterior aspects be pain free and return to her previous level of function, which was unremarkable; including foot and ankle landmarks. The included walking for at least one hour to go shopping. inter rater reliability of visual observation of posture has This patient signed and provided an informed consent to treatment when physical therapy was initiated, and signed an been supported by Van Dillen et al. [9] (Kappa values ≥.40 informed consent at the completion of her care, allowing the for 72% of items related to alignment and movement). production of a report about her case. Health Insurance and anterior and lateral sides, revealed that the patient walked Portability and Accountability Act (HIPAA) requirements for D. Gait:without Observational limping, with gait a mild completed bilateral frommedial the whip posterior, of her disclosure of protected health information were covered Table 2a feet. Visual gait observation is often used to determine & 2b. gait disorders and to evaluate treatment. A recent study on observational gait analysis showed it had moderate Examination

Phase I. Diagnosis: Refractory Plantar Fasciitis reliability [10] (Inter-rater reliability (ICC = 0.54; 95%CI: A. History: At the initial interview the patient reported that she extensively0.48–0.60); describedintra-rater by reliability Perry [11]. = 0.63 (ICCs 0.57 to 0.70). had had bilateral foot pain for 6 months with an exacerbation Gait analysis for normal and pathological function has been about two months prior to her examination. Initially, she and knees were estimated to be within normal limits and saw her primary care physician who gave her exercises and E. Range of Motion (ROM): Active and passive ROM of feet can be quickly assessed in the clinic visually, or with a pain continued to get worse and the physician referred her pain-free. Comparing sides, ROM measurements of limbs fora prescription physical therapy for an anti-inflammatorywith a diagnosis of medication. “refractory Her plantar foot universal long-arm goniometer. A recent study of intra tester

Citation:

Viel JPL, Andrade CK, Wanek L (2016) Clinical Red Flags in the Diagnosis of a Patient with Atypical Lower Limb Pain-A Case Report. MOJ Orthop Rheumatol 6(2): 00214. DOI: 10.15406/mojor.2016.06.00214 Clinical Red Flags in the Diagnosis of a Patient with Atypical Lower Limb Pain-A Case Copyright: 3/11 Report ©2016 Viel et al.

reliability for goniometric measurements of the knee found A 2003 Cochrane database systematic review conducted by Crawford et al. [17] determined that there is limited evidence that ultrasound therapy for heel pain is associated it to be high [12] (intra class correlation coefficients [ICCs] = with better outcomes than no treatment and control F. Strength:.997 in flexion, Manual = .972 muscle to .985 testing in extension). (MMT), as described by Kendall et al. [13], was used to assess the patient’s ankle/ both arches was done to relieve stresses on plantar fascia therapies such as stretching exercises. “Low Dye” taping of study completed by Lynch et al. [18] in 1998 showed that foot and knee strength. Foot plantar flexion strength was respectively and bilaterally, and all other movements were induced by weight-bearing. A randomized, prospective rated as 2/5 bilaterally, inversion and eversion as 4 and 3/5 fasciitis.taping and Home orthoses program were moreincluded effective ankle than inversion either anti-and rated as 5/5. Muscle testing can be done manually or with a inflammatory or modalities for the treatment of plantar hand-held dynamometer. Intra rater reliability is high [14]. were rated as normal and symmetrical. A study by Manshot towel gathering, 3 times 10 repetitions each to be done G. Deep tendon reflexes: Achilles deep tendon reflexes (DTR) eversion with towel on the floor; toe flexion/extension with J. Contrast baths: On the fourth visit patient was given verbal statistics,[15] showed was never that the better inter than observer “fair” (highest agreement kappa among value once-a-day. and written instructions for contrast baths with the goal of physicians on testing tendon reflexes, assessed with kappa alleviating pain. To date there are very few studies that have focused on the effectiveness of hot–cold water immersion H. Palpation:0.35). Patient reported a mild decrease of sensation with digital palpation over the ball of her feet and plantar surface of all ten toes. Plantar aspect of the 2nd and 3rd K. Outcomes: Patient reported on the fourth visit that bilateral metatarsophalangeal joints was reportedly moderately for the reduction of pain [19-20]. tender on palpation. Heels were not painful. seemed to bring most of the relief. She returned to her I. Interventions: The patient was seen for 6 physical therapy physicianfoot pain hadafter reduced the sixth by 10session, to 20%. at Thewhich arch point support her tapefoot strength had returned to normal in all directions except for aspects of 2nd and 3rd metatarsophalangeal joints, followingsessions overtreatment a 3-week protocols period. outlined Ultrasound by Cameron to plantar [16]. with her home exercise program. plantar flexion (2/5 bilaterally). She was very compliant

Table 2a:

Case Description. Medical Diagnosis Time Frame Key Findings P.T. Diagnosis

Metatarsalgia - Slight medial whip when walking. Mild pes planus - Bilateral 03/13/02 - Bilat. Plantar Flexion weakness(2/5) Initial Referral of Fasciitis (Physician) - Achilles’ DTR: WNL - Unclear etiology 1. Refractory Bilateral Plantar - Pain 2nd 3rd Met heads weakness - Nocturnal foot pain (4/10) Plantar flexion - Mild N/T both feet

8/10 pain. Insidious onset Two Months after - “Burning & tightness” of R knee with

- No limp - Mild synovitis Initial Referral - Mild effusion R knee (~1cm) metatarsalgia Syndrome - Chronic 2.(Orthopedic Right Patello-Femoral Surgeon) 05/13/02 - Quad strength: 4+/5 - ROM: WNL - RLE ¾” longer - Past History: Strained quad 1981 - Persistent foot pain 4/10

Five Months after - Insidious onset of low back ache over past 6 08/16/02 months (5-6/10) - Tenderness L5-S1 (R) compromission Initial Referral - S1 nerve root (Orthopaedic Surgeon) - Bilat SLR = 90º 3. Right Piriformis Syndrome medial- Slight hamstringsBilateral genu recurvatum - Depressed DTR’s R Achilles’ and

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Seven Months after

- “Burning pain” along post. aspect “Red Flag”

RLE 7+/10. Aggravated by sneezing, sitting; For insidious 10/21/02 L- Fallknee; 10/07/02 when L knee “buckled under”; Initial Referral - Gait abnormality with marked Hyperextension of possible demyelinating 4. Right Sciatica - Feet are “cold” all the time; neuropathy - No detectable tenderness in spinal segments (New Primary Md) - Spinal ROM= WNL & pain free; - R Achilles’ DTR = 0; - Hyperreflexic quads (3+ bilat)

Nine Months after 12/30/02 Same as above Initial Referral - Same findings as above 5. Left Ankle and Left Quad - Pt awakens 2-3 x night with back & LE pain Table 2b: InterventionsInsufficiency addressing (Orthop) patient’s complaints.

Medical Diagnosis Time Frame Initial Intervention Rationale

(MTPs); - U/S to metatarso-phalangeals

Initial Referral - Painful MTPs - Low dye taping of feet; Plantar 1. Refractory Bilateral 03/13/02 gathering ex’s; - Pes planus - Home Ex Program w towel Fasciitis (Physician)

- Metatarsal pads

- 6 sessions

Two Months after Initial lower extremities with closed - Progressive resistive exercises Referral chain ex’s - Effusion & weakness right knee. 2.RightSyndrome Patello-Femoral 05/13/02 - Cont same treatment for feet - Painful feet (Orthopedic Surgeon) - 14 sessions for both c/o’s

Five Months after

distribution; - Spinal flexion Ex’s. - Depressed Deep tendon reflexes (DTR), S1 Initial Referral 08/16/02 Syndrome - Lumbar Stabilization Ex’s 3. Right Piriformis Psychogenic symptoms? - Multiple musculo-skeletal c/o’s; - (Orthopedic Surgeon) - 4 sessions

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- Letter to PCP on 11/05/02

with- Second CC to letter neurologist to PCP 11/22/02 & orthopaedist

Seven Months After Initial mechanical back, hip, or sciatic nerve - Sx’s not consistent with common - No PT treatment irritation. Referral 10/21/02 - Pt saw PCP 4. Right Sciatica letter. - Quickly worsening Sx’s. 11/13. No feedback re. Red Flag (New Primary MD)

management- Referred by MDspecialist”. to a “pain

- Screened for mercury poisoning: negative findings.

Nine Months after 12/30/02 - Phone call to consulting Initial Referral andNeurologist. weakness Loss of LE’s of balance to be - Same as above 5. Left Ankle and Left Quad further assessed

Insufficiency (Orthop)

Phase 2. Diagnosis: Bilateral metatarsalgia improvements in foot pain. Patient began complaining of moderate left knee pain, 6/10 on VAS. orthotics and returned on her physician’s recommendation Phase 3. Diagnosis: Anterior Left Knee Pain A. History:for an additional One month six sessions.later, the patient had been fitted with A. History: On the third visit of the second series of treatment B. Posture/Observation: On observation the patient’s stood for her feet, patient presented an additional prescription without any abnormalities. from an orthopedic surgeon to address her left knee pain, which had insidiously appeared and was worsening. The diagnosis was “anterior knee pain”, to be treated with a to walk normally. C. Gait: Patient was assessed in three directions and appeared “closed chain program”, twice-a-week for three weeks. burning sensation and tightness”, which she rated at 8/10 D. Rangefree. of motion: Active and passive range of motion (ROM) B. Examination:(VAS). Pain-Patient described her knee pain as “a of feet and knees were again within normal limits and pain- E. Strength: Manual muscle testing found strength to be C. Observation: The patient’s standing posture observed from the anterior, lateral and posterior aspects was again normal. F. Palpation:normal except Plantar for ankle aspect plantar offlexion, the still 2nd 2/5 bilaterally.and 3rd metatarsophalangeal joints was still moderately tender on walked without abnormality. palpation. Heels were not painful. D. Gait: Patient was wearing a neoprene knee sleeve and

passive or accessory. tenderness of the metatarsal heads, working hypothesis E. Range of motion: Her knee ROM was normal, whether active, G. Physicalwas bilateral Therapist metatarsalgia. Diagnosis: Based on the moderate F. Palpation: There was no detectable tenderness upon palpation on or around the patella, and patellar tapping was H. Interventions: Low intensity ultrasound, soft tissue painless. mobilization, low dye taping, use of metatarsal pads, and general conditioning exercise program were initiated.

I. Outcomes: After 6 visits, there were minimal subjective G. Strength: Her knee strength was rated as normal (5/5). H. Girth Measurement: Measured with a vinyl tape ribbon,

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a possible S1 lumbar nerve root entrapment.

ofher circumferential knee mid-patellar measurements girth was 41.5obtained cm onwith the a right,tape vs. 40.5 cm on the left. Validity and inter rater reliability exercises. Lower abdominal muscle strengthening according J. Interventions:to Sahrmann’s Spinal protocol. flexion Set exercises up home and lumbarexercise stabilization program. Patient had four treatments. ofmeasure the knee have and been the reported found to knee be highpain, (ICCsthe diagnosis ≥ .98) [21].was internalPhysical knee Therapy derangement Diagnosis: with Because synovitis. of the mild effusion K. Outcomes: On the third visit, patient “was still hurting; not I. Interventions: The sessions addressed the knee and bilateral existent soft tissue tenderness, or muscular hyper tonicity, foot pain. The same strategies as outlined previously for feeling any better”. Palpation detected minimal, if not non- treating the patient’s feet were used, in addition to closed segments. On the fourth visit, patient reported feeling “maybe kinetic chain lower extremity strengthening exercises, and aanywhere little better”. along She the had lumbar seen a chiropractormake it tighter who or had lumbo-sacral performed general conditioning exercises on a cycling ergometer. a spinal adjustment because “her right hip was higher”. She J. Outcomes: At the completion of fourteen sessions, patient also reported that she woke up around 2 am every morning, returned to the orthopedic surgeon reporting that her knee with pain “crawling up the right side of her back”. “still burned a little but was getting better”. She was taking L. I was unable to corroborate patient’s complaints with any

Naproxen (Roche Products Pty Limited) and had stopped patient’s symptoms were possibly psychogenic. She still tangible findings. My hypothesis at that point was that taking Vioxx, “because she could not afford it”. Report to the physician indicated that it was difficult to corroborate without noticeable abnormalities. moved well, transferred without any difficulty, and walked discontinueher complaints physical with therapy tangible for objective lack of progress findings, was including made. Phase 5. Diagnosis: Right sciatica absence of reproducible symptoms. Recommendation to Phase 4. Diagnosis: Right hip pain A. History: Seven months after her initial referral, the patient returned with a prescription from her primary care A. History: The patient returned two months later, with a referral from the same orthopedic surgeon with a diagnosis physician with a diagnosis of “sciatica”. An MRI of her lower spine had been recently performed without findings. weeks.of “Right Piriformis Syndrome”, with instructions to perform She had a prescription for Vicodin 500mg (hydrocodone/ “hip stretching and conditioning”, twice-a-week for three was taking sporadically. She reported having fallen at work B. Examination: Patient reported having had insidious right aacetaminophen, month before, whenKnoll herLabs, left Mt. knee Olive, buckled NJ, U.S.A.), under which after she stood up from her chair and walked away from it. B. Examination: Patient’s chief complaint was a moderately departmenthip and right-sided store. Shelow reportedback pain herover pain the pastas moderate six months. to She was still working full-time as sign coordinator for a deep burning pain along the posterior aspect of the right hip severe (7-8/10 on VAS) to severe (“sometimes a 10/10”) C. Posture/observation:severe, 5-6/10 on VAS Observedscale. She fromwas taking three sides,four Aleves the patient a day. and the posterior thigh. She was not sleeping well because stood with a swayback, mild lumbar hyperlordosis, and of pain, never more than two hours at a stretch. Symptoms bilateral genu recurvatum. were aggravated by sitting, standing, and sneezing (the latter provoked burning pain in the posterior right thigh). C. Posture/Observation: Patient stood with the same D. Strength: Quadriceps, hamstrings and gastrocnemius/soleus swayback described earlier, lumbar hyperlordosis, and muscles tested 5/5. bilateral genu recurvatum. E. Deep tendon reflexes: DTR’s for right Achilles and right medial hamstring were depressed (=1). thigh pain, patient exhibited a gait abnormality with a extremities, whether movements were physiological or D. Gait:strong Although left dipping her primarylimp: she complaint locked her was left right knee hip into and F. Rangeaccessory. of motion: Was within normal limits in lower hyperextension throughout the stance phase. E. Balance: Tested in standing with her feet together and bilaterally without symptoms, either in the legs, the hip, or G. Neuralthe low tissue back. dynamics: Straight leg raise reached 90 degrees H. Palpation: There was no detectable tenderness in the lumbar her balance. eyes closed, the patient had a Romberg’s sign, being or lumbosacral segments and questionable tenderness in the unable to stand more than 5 to 6 seconds without losing F. Strength: Strength appeared normal throughout both lower extremities except for the left quadriceps, which was right sacro-sciatic notch or over the piriformis/gemelli group. sided low back and hip pain, as well as depressed Achilles’ I. Physical therapist diagnosis: Because of presence of right- weak (2+ to 3/5). G. Deep Tendon Reflexes (DTRs): She was bilaterally and medial hamstring DTRs, the diagnosis was formulated as hyperreflexic (3+ to 4) in the quadriceps, as well as the

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biceps brachii, and brachioradialis muscles (?). Achilles recommendation, patient sought the assistance of another neurologist, outside of her home territory. This neurologist

DTR was absent on the right. revealed a mass between T9 and T10 vertebral bodies, located in within norms in all directions and painless, even with therequested intradural a magneticextra medullary resonance space imagingof the spine test (Figure1 (MRI), & which 2). H. Range of motion: Lumbar spinal ROM in standing was bending. sustained overpressure in flexion, extension, or side-

I. Neural tension testing: Straight leg raise test was bilaterally normal at 80º. spine failed to reproduce right hip or leg symptoms. The J. Palpation: Direct and firm palpation/mobilization of her palpation, and her piriformis/gluteal muscles felt normal. right sacro-sciatic notch was questionably tender on

mechanical back, hip problems, or common sciatic nerve K. Diagnosis:irritation. They Symptoms were neither were notsevere, consistent nor irritable, with but common were unrelenting, chronic, and were seemingly getting worse.

poorThe patient balance, was and frustrated bilateral andfoot despondentsymptoms were over evocativeher long- ofstanding an insidious problems. neuropathy. Her hyperreflexia, Traditional gaitphysical abnormality, therapy strategies had not provided her with any lasting relief. L. Interventions: Signs and symptoms were unusual enough

warranted communication with her physician. In the mean timethat attempts her case to was temporarily considered alleviate to be her a “red hip and flag”, leg which pain with soft tissue work, electrical stimulation, and gentle exercises.

patient reported temporary relief of right hip and thigh M. Outcomes:pain for 2 to During 3 hours the after course each ofsession. this lastA letter intervention, was sent Figure 1: Schwannoma at T9 10, sagittal view.

and recommendation to discontinue physical therapy. -T Patientto the patient’s saw her primaryphysician care after physician the third outlining physical findingstherapy Phase 7. Surgical intervention and post-op course session. The physician had no feedback regarding the “red A. History: A neurosurgeon excised the mass, subsequently motor neuron or central nervous system problem, possibly diagnosed by a pathologist as a “schwannoma of benign multipleflag” letter. sclerosis. Objective Two findings weeks stilllater, lead a second toward letter an upper was nature” (Figure 3). Following surgery, the patient went sent, reiterating my concerns. walked with a walker for a week and a half, and returned to Phase 6. Diagnosis: Spinal Tumor home and was wheelchair-bound for three weeks. She

B. myExamination office 7 weeks after her surgery. after being evaluated by a neurologist. Patient reported that the A. History: Patient returned to our office six weeks later C. Posture/Observation: Patient stood with a swayback, bilateral genu recurvatum, more pronounced on the left. electromyographic (EMG) test performed had been determined as She walked slowly without an assistive device, locking her referred“normal”. her Neurologist to a pain had management given her aspecialist prescription (anesthesiologist) for Neurontin left knee into hyperextension during stance, with a left who(Gabapentin. performed Pfizer, a NY,lumbar NY). Herepidural primary injection. care physician The procedure had also “helped somewhat” her low back pain. Her physician also had the Trendelenburg’s sign, and had no push-off. patient tested for mercury poisoning and the test was negative. D. ROM: Was WNL throughout. prescription for physical therapy from her orthopedic surgeon E. Strength: Quadriceps were weak at 3/5; Hamstrings were withDuring a diagnosis that same of “left span ankle of time, and theleft patient knee weakness”. had yet another Since 4/5; gastroc/soleus groups were poor at 2-2+/5. her objective signs had not changed, on the undersigned 3; Achilles’ 2 on right and absent on the left. F. DTRs: Quadricipital DTRs were 3+; medial hamstrings 2+ to

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G. Neural tissue dynamics: Straight leg raise was measured at H. 90ºPhysical bilaterally. therapist’s diagnosis: Post spinal cord compression paraparesis. I. Intervention: Patient was treated for a total of 24 sessions over three months. Her program consisted of progressive strengthening exercises for her lower limbs, balance and

a home exercise program (HEP). She actively participated inproprioceptive her care, was exercises, faithful tocardio-vascular her HEP, and conditioning,did not miss andany sessions.

J. herOutcomes: feet still Patient“cramped” reported frequently, feeling and both 75 to hands 80% felt better tight strength-wise. She was sleeping well, through the night, but was fair to good; she could walk for one hour, and returned toand work achy 128 for 10days to after25 minutes her surgery. every morning.When I visited Her balance her at her house in January 2006 to obtain a signed informed consent form for writing this case report, she revealed that she was doing well and was enjoying a normal life. Her

withspinal physical and lower activities extremity involving ROM was walking. normal Patientand pain had free, a and her back and leg pain at rest was 0-1/10 and 1-2/10 abatement of her left lower limb, bilateral foot pain, and crampingnear complete of her resolution hands. of her motor and sensory deficits,

Figure 3: Schwannoma following Laminectomies at T8, T9, and T10.

Size of schwannoma = 32mm x 13.5mm Discussion The clinical presentation of spinal cord compression syndrome caused by a schwannoma is characteristically insidious.

and are not always preceded by back pain, as demonstrated inNeurologic this case symptoms report. In are our slowly patient, progressive the signs over and several symptoms months of myelopathy evolved from a case of bilateral foot pain and vague sensory loss to a moderately severe upper motor neuron lesion within a time span of sixteen months. This case is representative of the complexity encountered in the diagnosis and management

process and clinical management in a patient who had complex of these lesions. [22] The report described the decision-making

clinicalpain manifestations, practice include and the findings fact that for any which time therea patient is a presents scarcity withof scientific bilateral information. lower limb symptoms The implications or back ofand these leg pain findings without for

a positive straight leg raise test (SLR), clinicians should think about When a non-musculoskeletal signs and symptoms etiology. do not quickly lead to a probable cause of pain or dysfunction, it is important to think about a

Figure 2: Schwannoma at T , frontal view. bilateral leg symptoms in a patient is the most important clinical 9 10 differential diagnosis [23]. According to Martinez-Lage et al. [24] -T finding that might indicate a spinal neoplasm, followed by motor and reflex impairments, and finally by the absence of a positive

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that patients with spinal neoplasms commonly exhibit spinal whenstraight-leg this patient raise test. was Had initially we been referred: aware the of these bilateral facts, weakness there were of deformitiesand no spinal and deformity. this patient A did study not by have Mehlman a scoliotic et al.curve. [25] notes two findings which my colleague and I could have investigated foot pain, especially at night. Otherwise, the presentation of her foot plantar flexors (2/5) and her bilateral mild to moderate when patients present with atypical lower limb and low back symptoms. A final pointIn a recent may help study determining of signs and a differential symptoms diagnosis used to differentiate low back pain of a musculoskeletal origin from a musculoskeletalthis patient for each cause of theof firsther threesymptoms. times sheThe wasevidence referred was to ratherour office sparse did notand raiseof poor concerns quality about because the herpossibility symptoms of a werenon- diagnosispotentially of more musculoskeletal serious non-musculoskeletal back pain (i.e., disk condition herniation), in a tightness” of the right knee, which were not reproducible with 12-year-old girl, Fritz and Kelly [26] discovered that to make a palpationnon-specific: or manual e.g., diffuse examination; bilateral footinsidious pain, thenonset “burning of low back and pain and left leg pain, which I could not reproduce with either the most important finding to help rule in the diagnosis was active movements, direct palpation of the spine, hip or knee, or arethe usefulpresence for ofruling unilateral in a diagnosis leg pain, when carrying the testa specificity is positive. of The1.0. with the straight leg raise test. According to Sackett et al. [27] tests that have high specificity Suspicion that this patient had a serious problem came only high sensitivity are useful for ruling out a diagnosis when the when she returned with her fourth referral. Her symptoms were straight-leg-raise test had a high sensitivity 0.88. Tests that have dramatically different than they had been in the past, such as her negative, the chance of a disk herniation decreases. On the other gait abnormality, walking with a dipping left limp and locking her hand,test is considering negative,24 testsindicating for spinal that, neoplasms, if the straight-leg-raise the most important test is knee in a marked recurvatum from foot strike to end of stance her precarious balance, and her diffuse lower limb numbness finding that would help to rule in this diagnosis would be the andphase. tingling Her hyperreflexia lead to the insuspicion all extremities, that she her was weak developing quadriceps, a presence of motor weakness, because this finding has a high demyelinating disease such as multiple sclerosis, or a neuropathy theirspecificity presence (0.94), might as helpwell rulingas bilateral in a diagnosis leg pain of with spinal a specificityneoplasm of toxic origin. Presence of a spinal cord lesion was not suspected, (Tableof 0.82. 3). Impaired reflexes have a lower sensitivity of 0.69, but since there was no detectable tenderness at the thoracic level,

Table 3: Physiological outcomes.

Goal(s) Physical Time Frame Initial Outcome Final Outcome Explanation Therapist’s or Pt’s

- Temporary Dx#1:Plantar Fasciitis for ½ Relief of foot pain “Feet feel ~ 10 - 20% Better” possibly psychogenic - Suspicion that patient’s foot pain is - Alleviate Foot Pain 03/13/02 day after Ankle strength 5/5 R, 4/5 L, treatment except for PF = 2/5 bilaterally - Improve Walking

Syndrome Dx#2:Patello-Femoral compensatory movements. - Patient walked Without limping or a little; stiff, but corroborating pt’s knee - “Knee still burns symptoms- No tangible Both findings feet still sore - Reduce Knee getting better” 05/13/02 reproducible.- Knee Sx’s were not Inflammation

- Strengthen Rle

Syndrome Dx#3:Piriformis better” - R hip & LB pain “May be a little psychogenic- Suspicion that 08/16/02 Sx’s persisted. Irritation-Reduces1nerve Root - No change in subj Sx’s (LBP=7/10) - Saw a Chiro 9/18 because right changehip was with “higher”. chiro No treatment

- No objective abnormalities. - Alleviate Lbp

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Sx’s,- Dramatic not consistent change in with “classic” Dx#4:Right Sciatica sciatica. - N/A. “Red flag” letter PT- RLE pain better to primary MD - Alleviate Rle Pain 10/21/02 for 2-3 hours after - Aberrant - Strengthen L Knee Neurological Sx’s worsening. - RLE pain

management from PCP or from new neurologist because of lack Dx#5:Left Quadriceps neurologist.- Patient unsatisfied with mercury- Tested for poison: of- Patient response seeked from consult PCP re. with 12/30/02 Insufficiency. negative - Strengthen L Knee - Patient’s frustrations And L Ankle Red Flag letter. Worsening.

x/night- Awakens w pain2-3

Conclusion Intramedullary neuroma of the cervical spinal cord: case report. Spinal Schwannomas are uncommon and can cause compressive neurologic symptoms affecting both lower 6. Neurosurgery 39(3): 594-598. limbs, which are usually insidious in onset. This case report is The American Heritage® Stedman’s Medical Dictionary Copyright representative of the complexity encountered in the diagnosis 7. © 2002, 2001, 1995 by Houghton Mifflin Company and management of lower limb pain and it demonstrates the need for physical therapists to listen to a patient’s complaints, Albanese V, Platania N (2002) Spinal intradural extramedullary 8. tumors. Personal experience. J Neurosurg Sci 46(1): 18-24. even when these do not always make sense objectively. Clinicians need to perform a comprehensive neurological examination Jenkinson MD, Simpson C, Nicholas RS, Miles J, Findlay GF, et al. whenever patients report bilateral limb symptoms, even if they (2005) Outcome predictors and complications in the management 9. are as common and distal as foot pain. They also need to develop of intradural spinal tumors. Eur Spine J 15(2): 203-210. Van Dillen LR, Sahrmann SA, Norton BJ, Caldwell CA, Fleming DA, diagnostic tests. 988.et al. (1998) Reliability of physical examination items used for proficiency at interpreting the best available evidence related to classification of patients with low back pain. Phys Ther 78(9): 979- 10. some directions for future work and research on the topic of spinal neoplasmsFinally, theand clinical their repercussions, findings highlighted especially in this at casethe thoracic suggest Brunnekreef JJ, van Uden CJ, van Moorsel S, Kooloos JG (2005) Reliability of videotaped observational gait analysis in patients with 11. orthopedic impairments. BMC Musculoskelet Disord 17(6): 17. plentiful, whereas studies of the thoracic region are scarce [20]. level. Scientific information on cervical and lumbar problems is Perry J (1994) Gait Analysis: Normal and Pathological Function. References 12. Thorofare (ed) Slack Incorporated, New Jersey, USA. 1. parallelogramBrosseau L, Balmer and universalS, Tousignant goniometers M, O Sullivan for measuringJP, Goudreault maximum C, et al. Therapy. 3rd (2001) Intra- and inter tester reliability and criterion validity of the Goodman C, Snyder T (2000) Differential Diagnosis in Physical 2. (edn), Saunders Foreword, Philadelphia, USA. active knee flexion and extension of patients with knee restrictions. Primary Care for the Physical Therapist: Examination and Triage St 13. ArchKendall Phys F, MedMc Creary Rehabil E, 82(3): Provance 396-402. P (1999) Muscles: Testing and LouisGodges 2nd J (2005) Symptom Investigation. In: Boissonault WG (ed). Function with Posture and Pain. Lippincott Williams and Wilkins,

3. Fox MW, (edn),Onofrio Elsevier-Saunders, BM (1993) The natural Philadelphia, history USA, and pp. management 66-86. of symptomatic and asymptomatic vertebral hemangioma. J 14. Baltimore, USA. Wadsworth CT, Krishnan R, Sear M, Harrold J, Nielsen DH (1987) 4. Neurosurg 78(1): 36-45. Intra rater reliability of manual muscle testing and hand-held dynamometric muscle testing. Phys Ther 67(9): 1342-1347. Gelabert González M, Garcia Allut A, Conde Alonso C, Bollar Zabala A, Martinez Rumbo R, et al. (1985) Intra medullary spinal 15. S Manschot, L van Passel, E Buskens, A Algra, J van Gijn (1998) neurofibroma diagnosed with computed tomography: report of a Mayo and NINDS scales for assessment of tendon reflexes: between Melancia JL, Pimentel JC, Conceiçäo I, Antunes JL (1996) case. Neurosurgery 16(4): 543-545. observer agreement and implications for communication. J Neurol Neurosurg Psychiatry 64(2): 253-255. 5.

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Viel JPL, Andrade CK, Wanek L (2016) Clinical Red Flags in the Diagnosis of a Patient with Atypical Lower Limb Pain-A Case Report. MOJ Orthop Rheumatol 6(2): 00214. DOI: 10.15406/mojor.2016.06.00214