RESUMO
Non-specific low back pain without identifiable causes on imaging is a common and frustrating problem for both patients and physicians. While proximal symptoms such as shoulder pain from distal upper extremity neuropathies such as carpal tunnel syndrome are well-known, peripheral neuropathy of the foot or ankle is rarely considered in the differential diagnosis for low back pain. This study aims to highlight the potential link between chronic ankle instability (CAI) and low back pain. We present three cases: a 32-year-old woman with chronic low back pain for over 10 years, a 59-year-old woman with transient low back pain after long drives, and a 42-year-old woman with acute low back pain while gardening. All patients had normal imaging studies but exhibited CAI on examination. Diagnostic modalities included the ankle anterior drawer test, application of ankle brace, superficial peroneal nerve (SPN) blocks, and assessment of the active straight leg raise (aSLR) angle. In the first case, low back pain disappeared after SPN neurolysis and ankle ligament reconstruction. The second case showed significant improvement in aSLR and pain reduction with SPN block and ankle brace. The third case experienced substantial pain relief with the use of an ankle brace. These findings suggest that addressing ankle instability and associated traction neuropathy can significantly alleviate low back pain symptoms. CAI may be an underrecognized cause of non-specific low back pain. Interventions such as ankle brace, SPN blocks, SPN decompression, and ankle ligament reconstruction can be effective for diagnosis and treatment, potentially offering relief for patients with chronic low back pain.
RESUMO
As a referral center for chronic pain, we see many patients with "idiopathic" shoulder pain and limited range of motion. The combination of mild or subclinical carpal tunnel syndrome and cubital tunnel syndrome may be an underrecognized etiology of symptoms in such patients. Here, we report our treatment algorithm and results for such patients. METHODS: Of patients with a chief complaint of shoulder pain, we identified 56 consecutive patients who had pain or tingling with median nerve compression at the proximal wrist crease and positive Tinel's around the cubital tunnel. They were first provided a night-time wrist orthosis. If still symptomatic, nerve blocks were given to median and ulnar nerves under ultrasound guidance. If symptoms recurred after nerve blocks, nerve conduction studies and surgical release of affected nerves were performed. RESULTS: Six patients had 60% or more pain relief with orthosis (mean 4.7 ± 0.8 (SD) to 2.2 ± 0.8). Twenty-three patients had nerve blocks and had persistent pain relief (6.0 ± 1.7 to 2.1 ± 1.9) and significant shoulder motion improvement. Twenty-seven patients only had temporal relief and required surgery but postoperatively had persistent pain relief (6.2 ± 2.0 to 1.2 ± 1.0) and improved shoulder motion. qDASH improved from 33.4 ± 20.1 preoperatively to 12.2 ± 7.4 postoperatively. CONCLUSIONS: All patients had substantial improvement in shoulder pain and motion with compressive neuropathy treatments. Targeted physical examination can identify these patients, who can have significant improvement with appropriate diagnosis and treatment. The study sheds light on an underrecognized cause of shoulder dysfunction.