Written by the Summit Professional Education Team, experts in continuing education for healthcare and allied professionals
When patients walk into a physical therapy clinic, they often arrive with a stack of imaging results and a referral from their primary care provider. But what happens when the pictures don’t match the symptoms? That’s exactly the case with a 65-year-old endurance horseback rider who came to PT with a frustrating problem: numbness in his feet that appeared every time he spent hours in the saddle.
This case highlights the power of a thorough clinical assessment and conservative treatment, reminding us that while imaging can reveal a lot, it doesn’t always tell the whole story.
The Challenge: Foot Numbness in the Saddle
Our patient was a long-distance horseback rider who routinely completed endurance rides of more than 100 miles. Over time, he developed progressive numbness in his third and fourth toes, first on the left, then on the right.
Naturally, his providers suspected his spine. After all, his imaging showed a typical list of findings:
- Chronic fractures (pars defects) at L4
- A slip at L4–L5 (anterolisthesis)
- Narrowing of the spinal canal
With his imaging, it was recommended that he undergo an L4/5/S1 lumbar fusion.
Looking Closer: The Clinical Exam
Despite the imaging (which we know can be present in asymptomatic patients), his exam told a different story:
- His strength, reflexes, and sensation all tested normal.
- Spine-based symptoms were negative.
- Palpation near the sural nerve along the lateral aspect of his B calves reproduced his numbness.
- Straight leg test with sural N bias revealed symptoms on the left side more than the right.
On testing, this didn’t present as a classic lumbar radiculopathy. The problem wasn’t coming from the spine. Instead, the sural nerve, which runs down the back of the calf into the foot, was the culprit due to overuse and prolonged standing in dorsiflexion (with knee flexion, so the soleus muscle was the primary issue).
The Plan: Conservative Care First
Rather than lumbar surgery, treatment focused on calming down the irritated nerve and restoring mobility. Interventions included:
- Neural flossing (gentle nerve mobility drills)
- Soft tissue mobilization of the calf and surrounding tissues
- Dry needling of the gastrocnemius, soleus, and fibularis muscles
- A simple home program of nerve glides and foam rolling
The Outcome: Back in the Saddle
Within just three visits, the rider noticed a major difference:
- His numbness and tingling were gone.
- Pain dropped to almost nothing (1/10 at most).
- He was back to long-distance riding, without worrying about surgery.
By focusing on a thorough eval, patient history, and clinical findings rather than the dramatic findings on imaging, conservative care helped him fully return to the activities he loves.
Why This Matters
This case is a reminder that imaging findings often do not correlate with symptoms. Pars defects, disc degeneration, and narrowing are common, even in people without symptoms, especially as we age. What really matters is the clinical exam and how symptoms behave in real-life situations.
For this rider, the difference between surgery and recovery came down to careful reasoning, hands-on assessment, and targeted interventions.
References
- Maugeri G, D’Agata V, Trovato B, et al. The role of exercise on peripheral nerve regeneration: from animal model to clinical application. Heliyon. 2021;7(11):e08281. Published 2021 Oct 29. doi:10.1016/j.heliyon.2021.e08281
- Abbas A, Assimakopoulos D, Mailis A. Diagnosis and conservative management of sural neuropathy: a case report. J Can Chiropr Assoc. 2023;67(1):67-76.
- Kamper SJ, Logan G, Copsey B, et al. What is usual care for low back pain? A systematic review of health care provided to patients with low back pain in family practice and emergency departments. Pain. 2020;161(4):694-702. doi:10.1097/j.pain.0000000000001751
- Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. doi:10.3174/ajnr.A4173
- Oei MW, Evens AL, Bhatt AA, Garner HW. Imaging of the Aging Spine. Radiol Clin North Am. Jul 2022;60(4):629-640. doi:10.1016/j.rcl.2022.03.006
- Linton AA, Hsu WK. A Review of Treatment for Acute and Chronic Pars Fractures in the Lumbar Spine. Curr Rev Musculoskelet Med. 2022;15(4):259-271. doi:10.1007/s12178-022-09760-9
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