Foot Numbness - Basketball

Abstract

HISTORY: 35 year old male on phentermine for weight loss, presented to sports clinic with complaint of right foot numbness that started 6 days prior. After a basketball game he noticed pain and swelling in his postero-lateral calf. He went hiking the next day and the pain increased. The next day he developed numbness to the bottom of his foot. He saw a podiatrist on day 4 and was diagnosed with radiculopathy and given Medrol. He did not have foot drop or weakness but complained of heel numbness. At the time of his visit, his pain had mostly resolved, the numbness is what persisted and brought him in. PHYSICAL EXAM: Msk: Spine: No midline tenderness, FROM, 5/5 strength all lumbar dermatomes, decreased sensation to touch over heel and lateral foot Negative neural slump test, straight leg raise, Patricks, Fortins, Gaenslens, 1+ patellar and achilles reflexes Compartments soft, but right leg with swelling compared to left, no warmth, redness or cords, mild tenderness laterally DIFFERENTIAL DIAGNOSIS: Lumbar Radiculopathy Peripheral nerve entrapment Compartment syndrome DVT Hematoma/mass Partial gastrocnemius rupture TESTS & RESULTS: L-spine xray: L3/L4 retrolisthesis. Sono: no DVT MRI R leg: Grade 2 popliteus strain with edema/hematoma formation and compression of tibial nerve Initial labs (1 week post injury): CK 856, Cr 1.3, UA 1+ protein, 1+ ketones. CBC, CMP, ESR, and CRP normal Repeat labs (3 weeks post injury): normal CK, creatinine, UA EMG with nerve conduction (3 weeks post injury): normal Repeat MRI (6 weeks post injury): interval improvement yet persistent edema of the popliteus muscle Xrays tib/fib/knee (6 weeks post injury): no evidence of heterotopic ossification FINAL WORKING DIAGNOSIS: Tibial nerve compression due to popliteus muscle injury with concomitant mild rhabdo TREATMENT: Phentermine was stopped. He started PT after a 6-week period of rest from weight bearing exercise. OUTCOME AND FURTHER FOLLOW-UP: The patient’s symptoms improved with rest and physical therapy. There was a discussion about seeing a nerve surgeon, or doing a cortisone injection or nerve hydro-dissection, but the patient declined since he was improving. 6 weeks post injury he reported only mild numbness in his heel. RETURN TO ACTIVITY: The patient was able to gradually return to cardio and was back to basketball at 3 months.