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Letters to the Editor  |   April 2010
Response
Author Affiliations
  • John M. Lavelle, DO
    Boston University Medical Center, Massachusetts
Article Information
Emergency Medicine / Neuromusculoskeletal Disorders / Osteopathic Manipulative Treatment
Letters to the Editor   |   April 2010
Response
The Journal of the American Osteopathic Association, April 2010, Vol. 110, 224-225. doi:10.7556/jaoa.2010.110.4.224
The Journal of the American Osteopathic Association, April 2010, Vol. 110, 224-225. doi:10.7556/jaoa.2010.110.4.224
I appreciate the interest shown by Benjamin M. Sucher, DO, in the case report that Dr McKeigue and I wrote for the December 2009 JAOA.1 Dr Sucher discusses a vital issue in regard to the diagnosis of drop foot. As he mentions in his letter, it is essential to rule out severe causes of drop foot. Therefore, a detailed history and physical examination, including an appropriate osteopathic examination, of the patient are necessary. Further diagnostic testing, such as magnetic resonance imaging or electrodiagnostic testing, should be performed if the diagnosis remains unclear and if the results of these tests would change the treatment of the patient. Nerve conduction testing and electromyographic examination are important adjuncts in localizing the cause of injury, in determining the extent of damage, and in making a prognosis for the patient. 
After severe causes of injury have been ruled out by detailed neurologic and osteopathic examinations, the first treatment approach used by the osteopathic physician should be conservative application of osteopathic manipulative treatment (OMT). 
As Dr Sucher suggests, the patient in our case report1 likely had a simple crush injury, without focal demyelination, resulting from nerve compression with the fibular head. This type of simple nerve injury was originally classified by Seddon2,3 as neurapraxia that “occurs with a crush or sustained compression to an area of the body where a peripheral nerve is vulnerable.” Seddon4 also states, “Recovery from [neurapraxia] is remarkably rapid—indeed, so speedy that it cannot possibly be explained in terms of axonal regeneration.” Furthermore, Salter5 notes the following in regard to neurapraxia: 

There is only slight damage to the nerve with transient loss of conductivity, particularly in its motor fibers. Wallerian degeneration (breakdown of the myelin sheaths into lipid material and fragmentation of the neurofibrils) does not ensue and complete recovery may be expected within a few days or weeks.

 
For the patient featured in our case report,1 we concluded that the nerve injury was secondary to compression of the fibular head, based on findings within the detailed physical examination. According to Siegel,6 “Neurapraxia related to pressure has an improved prognosis if the nerve is decompressed early.” Dr McKeigue and I1 believed that with removal of the compressing force (ie, the fibular head), recovery of the patient would be complete and rapid. Neuropraxia has been described as “a true `nerve concussion'...Applying manual therapy here can speed up the recovery process and facilitate a complete recovery.”7 Therefore, simple—yet precise—OMT was performed on this patient to relieve the nerve compression. The routine techniques of OMT that we used allowed us to avoid additional, potentially painful diagnostic testing. 
Our unusual case1 exemplifies the importance of focusing on the initial history and physical examination of the patient, as well as of using OMT before pursuing further, expensive diagnostic workups and treatments. Additional diagnostic and treatment approaches should be used only if necessary to determine a definitive diagnosis and improve quality of care. 
All osteopathic physicians should be capable—based on their training in osteopathic medical school—of performing the same simple OMT techniques that we used with the patient in our case.1 Osteopathic physicians develop unique and essential skills during their medical training—skills that allow them to conservatively manage the simple yet debilitating medical conditions that they sometimes encounter in their offices. 
Lavelle JM, McKeigue ME. Musculoskeletal dysfunction and drop foot: diagnosis and management using osteopathic manipulative medicine. J Am Osteopath Assoc. 2009;109(12):648-650. http://www.jaoa.org/cgi/content/full/109/12/648. Accessed March 1, 2010.
Seddon HJ. Three types of nerve injury. Brain. 1943;66:247-288.
True JM. Nerve injuries in competitive sports. In: Hyde TE, Gengenbach MS, eds. Conservative Management of Sports Injuries. 2nd ed. Sudbury, MA: Jones and Bartlett Publishers;2007 : 349.
Seddon HJ. A classification of nerve injuries. Br Med J. 1942;2(4260):237-239. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2164137/. Accessed March 1, 2010.
Salter RB. Textbook of Disorders and Injuries of the Musculoskeletal System. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 1999:328 .
Siegel IM. Neurologic complications to orthopedic trauma and treatment. In: Vinken PJ, Bruyn GW, eds. Systemic Diseases, Part II: Handbook of Clinical Neurology. Amsterdam, The Netherlands: Elsevier Science BV; 1998:35 .
Barrel JP, Croibier A. Manual Therapy for the Peripheral Nerves. Philadelphia, PA: Churchill Livingstone;2007 : 30.