Leg & Foot Numbness & Tingling: Diagnosis & Treatment

leg and foot numbness and tingling is a very common problem if the leg and foot numbness and tingling is in just one of your legs then there are six most common causes of those symptoms and we're going to talk about each of them as well as how to treat each of those causes in just one moment now if the leg numbness and tingling is in both of your legs and or the feet then there's a not so lucky seventh cause that we'll be discussing as well and finally we're going to talk about an exciting diagnostic twist at the end of this video and this twist is going to have very important clinical implications that you won't want to miss whether you're a patient or if you're a doctor so please stay tuned for that hello I'm Dr Grant Cooper at Princeton spine and joint Center and when you think of diagnosing and then treating leg Andor foot numbness and tingling the first thing to recognize is that numbness and tingling are clear symptoms of nerve irritation so if you're having these symptoms then somewhere in your body your nerves are upset now we can figure out where your nerves have gone wrong by exploring the most common patterns that nerves go wrong in and what we'll see is that in the legs and the feet it almost always comes down to one of seven causes if the numbness and tingling is confined to the bottom of the foot then that's in the distribution of the posterior tibial nerve now there are three common problems that can lead to symptoms in the posterior tibial nerve distribution the most common is actually a pinch nerve in the back if someone has an S1 radiculopathy or inflammation around the S1 nerve rout as it exits the spine then this can cause pain numbness Andor tingling radiating down the back of the leg and into the foot it can however skip the buttock and thigh and even skip the lower leg completely and just present as numbness and tingling in the bottom of the foot if you have a pinched or inflamed S1 nerve root then treatment generally begins with targeted exercise to support the spine see the reason that exercises for your back work so well when they're done correctly is that your spine relies on the muscles tendons and ligaments that attached to it in order to support it it's like this if you take your spine out of your body and you place it on the ground your spine could support about a 35 lb axial load before it would start to break up now matter how thin you may or may not be you weigh more than 35 lbs we all do so we all rely on our muscles to support our spine in this way our spine is like a mast on a sailboat a mast on a sailboat if it just stood there with nothing attaching to it it would fall over because it wouldn't be able to support its own weight and that's why if you look at a sailboat there's all that rigging that attaches to the Mast the rigging supports the Mast and in the same way our muscles attached to to our spine to support our spine so back to the S1 pinch nerve if we can get our muscles to do a better job of supporting our spine then that can take the pressure off of the nerve root and allow the nerve route to heal now these exercises often involve core strengthening hip flexor stretching hamstring stretching thoracic and lumbar spine Mobility exercises as well as other exercises that will be specific to you in order to make sure you have no muscular imbalances we have a great video on back pain exercises and we'll be sure to put a link in the description of that video if you want to check it out later if Physical Therapy isn't helping enough then sometimes an epidural steroid injection will be used to reduce the inflammation and the swelling from around the nerve root an epidural steroid injection can reduce the inflammation and the swelling which in turn can reduce or eliminate the symptoms but of course an epidural is not changing the underlying biomechanics so if an epidural steroid injection is used then it should always be used as a window of opportunity so that while the inflammation is gone you can focus on the correct exercises in order to tweak the biomechanics enough so that the inflammation does not ever return if symptoms persist despite aggressive conservative care then sometimes a surgical decompression of the nerve rout is needed in order to mechanically decompress the nerve now other times the spine may need to be decompressed and fuse as well in order to stabilize that segment of the spine now there are other alternative treatments as well that are often worth considering and these would include most notably acupuncture as well as gentle Chiropractic Care ideally these alternative treatments can be used as part of a more comprehensive conservative care plan for me no matter what treatment plan is utilized even if someone ultimately needs surgery exercises alongside and on the back end of that treatment should always be planned on in order to improve the biomechanics and make it less likely that someone develops a similar spinal problem or or any spinal problem for that matter in the future the next most common cause of symptoms in the bottom of the foot is irritation of the tibial division of the sciatic nerve as it passes through or around the Pu formis muscle in the buttocks usually with sciatica the pain will be in the buttock and radiate down the back of the leg into the foot sometimes however it will just present with numbness and tingling in the bottom of the foot treating true sciatica that is compression of the sciatic nerve often involves physical therapy in order to use soft tissue mobilization on the Pu formis muscle and teach the patient exercises that he or she can then do in order to stretch the purform muscle and the surrounding muscles as well as to strengthen the purforms and the surrounding muscles nerve Glides are often quite helpful with sciatica as well now occasionally an injection called a sciatic nerve block can be done in order to reduce the inflammation from around the nerve of note when nerve blocks are done they should always be performed under ultrasound guidance both for safety as well as to make sure that the medication in the nerve block is placed in the optimal location a trigger point injection into the pur formis muscle which is often in spasm in true sciatica can be helpful as well now surgical release of the sciatic nerve can also be done it's uncommon but it can be performed by releasing a portion of the pure formis muscle the third most common cause of symptoms in the bottom of the foot is when the posterior tibial nerve is inflamed and or compressed inside of the tarsal tunnel this is what is known as tarsal tunnel syndrome you've probably heard of carpal tunnel syndrome carpal tunnel syndrome is an entrapment of the median nerve in the wrist and it's the most common peripheral nerve entrapment in the human body tarsal tunnel syndrome is the most common peripheral nerve entrapment in the lower leg tarsal tunel syndrome is more common in people with flat feet and who wear shoes with poor support tarsel tunnel syndrome symptoms are generally worse after you've been on your feet for a long time because when you stand you tend to put mechanical pressure on the tarsal tunnel itself this pressure is worse if you have flat feet or if you have mechanics that predispose to your ankle rolling inwards onto the tunnel which of course in turn puts more pressure on the posterior your tibial nerve which is inside of the tunnel now this is why one of the first line treatments for tarsal tunnel syndrome if you do have flat feet which is also known as hyperpronation is a good orthotic in your shoe in order to help restore the arch and therefore take the pressure off of the tunnel if an orthotic is not helpful or not helpful enough then there are other good treatment options physical therapy is one conservative measure that can be very helpful for tarsal tunnels syndrome in conjunction with an orthotic Physical Therapy will focus on strengthening the intrinsic foot muscles as well as the muscles around the ankle in order to help support the arch and stabilize the ankle now Physical Therapy will also utilize passive modalities such as soft tissue mobilization to reduce swelling and increase mobilization in and around the tunnel as well as nerve Glides to specifically break any adhesions increase mobility and reduce swelling around the posterior tibial nerve in particular an ultrasound guided steroid injection is sometimes used to treat moderate or severe tarsal tunnel syndrome the injection reduces the swelling and the inflammation in the tarsal tunnel which then takes the pressure off of the posterior tibial nerve it's important that if you use an injection to take away the inflammation that you also use better Footwear Orthotics and exercises in order to address the biomechanics after the injection has alleviated the inflammation finally it's rare but sometimes surgery is needed to decompress the tarsal tunnel in order to release the pressure on the posterior tibial nerve inside of the tunnel this is called a tarsal tunnel release and it involves releasing the flexor retinaculum and a septum that compartmentalizes the medial and the lateral planter nerves and the overlying fascia of the abductor hysis muscle if the symptom are in the lateral aspect of the lower leg and or in the top of the foot then this is in the distribution of the peronal nerve when someone has numbness and tingling Andor pain in the lateral aspect of the lower leg Andor the top of the foot then this is also usually due to one of three causes I just need to pause very briefly and make a request of you if you're enjoying this content and if you're learning something useful please go ahead and press the like button as it helps us with our YouTube algorithm and also please subscribe to our Channel thank you very much the most common cause of symptoms in the lateral aspect of the lower leg Andor in the top of the foot once again is from the spine if someone has an L5 pinched nerve in the back then this will often present with back pain and buttock pain and pain radiating down the leg and into the top of the foot however sometimes it will present with only numbness tingling and or pain in the top of the foot one would treat an L5 pinch nerve in the same way as an S1 pinch nerve with exercises Physical Therapy sometimes an injection at times alternative treatments such as acupuncture and gentle chiropractic care and occasionally with surgery the second most common cause of numbness and tingling in the lateral aspect of the lower leg Andor in the top of the foot once again is compression and irritation of the sciatic nerve as it passes through or around the purform muscle this is an interesting point about the sciatic nerve that you might not have known the sciatic nerve has two divisions of it it has a peronal division and a tibial division that together form the sciatic nerve now if the tibial division is affected as we discussed before then the symptoms will occur in the bottom of the foot but if the peronal division is affected and the peronal division is the more common division of the sciatic nerve to be affected because the peronal division has a more lateral position and this actually makes it more vulnerable to injury now if the perinal division of the sciatic nerve is affected then the symptoms will be in the lateral aspect of the lower leg Andor the top of the foot treatment for compression or irritation of the peronal division of the sciatic nerve is going to be the same as for treatment of the tibial division of the sciatic nerve now namely this will mean exercises Physical Therapy occasionally ultrasound guided nerve blocks or trigger point injection and very rarely surgical release now to give a sense of how rare surgical release of the sciatic nerve would or perhaps should be let me offer my own clinical perspective I've been seeing patients with these types of symptoms for two decades and I've liter literally never had a patient go for a sciatic nerve surgical release on top of that when I was at Columbia University Hospital Cornell Hospital special surgery and in our own group here at Princeton spine and joint Center I've never met a colleague who told me they have sent a patient for surgical release of the sciatic nerve and no one has ever presented about such a patient in a ground rounds or in journal club now this is definitely not to say that it's never necessary but it's rare because almost all all patients with Sciatic compression get better with conservative care now again some patients will need a surgical release but my point is just that the overwhelming majority will get better with good conservative care the third most common cause of numbness and tingling in the lateral aspect of the lower leg and or the top of the foot is a compression of the peronal nerve itself the peronal nerve passes around the fibular head beneath thee knee at the top of the lower leg as it does this the peronal nerve passes close to the surface of the leg and is therefore very vulnerable to compression for any of my martial artists out there when you see Fighters throwing lower leg kicks they're targeting the peronal nerve in their opponent if they can hit the peronal nerve the nerve suffers an injury and their opponent temporarily loses their ability to dorsy flex or lift up their foot basically they're trying trying to give their opponent a foot drop and it's very hard to move when you're dealing with a foot drop now this happened to Jimmy crout in his fight against Anthony Smith uh it happened to Henry cejudo Triple C in his title fight against Demetrius Johnson and it also happened to Conor McGregor when he fought Dustin porier more commonly the reason that someone develops a peronal nerve injury at the fibular head is if they had a cast on that wasn't fitting quite properly and then that cast was putting pressure on the nerve now also if someone's been lying down a lot and they happen to be putting pressure on the nerve by the position of their leg then this is a common cause for it as well this is something that doctors are or at least should be on the lookout for in the hospital when patients are in bed for extended periods of time now other risk factors would include wearing high boots um and also crossing your legs regularly which can also end up with repeated pressure being placed on the nerve treating a peronal nerve and Tra at the fibular head first involves removing the offending problem so if a cast is putting pressure on the nerve adjust the cast if a person is crossing their legs and putting pressure on the nerve that way don't do that if the person is wearing high boots that puts pressure on the nerve that way it's time for some new boots if there's a cyst that's compressing the nerve then the cyst should be drained popped or otherwise surgically removed once the offending problem is gone often it just take some time for the symptoms to resolve Physical Therapy can be helpful to speed recovery nerve Glides and soft tissue mobilization can be helpful if there's a foot drop then certainly therapy will be helpful in building up that muscle again now if the numbness Andor tingling symptoms are in both of your feet in a fairly symmetric pattern then this may be a symptom of what we would call the peripheral neuropathy a peripheral neuropathy is a another way of saying that there's a generalized problem with the nerves peripheral neuropathy symptoms often show up first in the toes and the feet this is because the nerves to the toes and the feet are the longest peripheral nerves in the body and are therefore also the most vulnerable you could think of a peripheral neuropathy as similar to wear and tear of the nerves or wear and tear of any other structure in the body such as the joints and indeed about half of all the peripheral neuropathies don't actually have an identifiable cause we call those neuropathies idiopathic now someday we may be able to identify an underlying cause for those neuropathies but for now we tend to think of them as akin to wear and tear of the nerves the most common type of peripheral neuropathy that we can diagnose with a clear cause that's a peripheral neuropathy where we know why it's happening and the one that many people think of when they hear about a peripheral neuropathy is a diabetic peripheral neuropathy when someone has uncontrolled or poorly controlled diabetes for many years the nerves can become affected and start to not work properly and we find that about half of people with diabetes do in fact have some form of nerve damage there are many other causes of peripheral neuropathies in fact whole books are devoted to the many other causes now some of the more common causes include low vitamin B12 thyroid problems low folate smoking infections such as Lyme disease HIV chronic kidney disease certain types of cancer a history of certain kinds of chemotherapy and a host of other potential problems basically though for our purposes right now if you have numbness and tingling in both of your feet and if those symptoms are symmetric and if those symptoms don't change regardless of what you're doing for example if the symptoms don't get particularly better or worse with sitting or standing or walking then a peripheral neuropathy is very high on the list of potential diagnoses on the other hand if you have bilateral numbness and tingling in your feet that gets worse when you walk and goes away when you sit then a peripheral neuropathy would remain on the differential diagnosis list as a possible cause but spinal stenosis where the nerves are being impinged in the spine is much more likely since when you stand the symptoms are worse suggesting they're being impinged when you stand and when you sit the symptoms go away suggesting that with spinal flexion the pressure is taken off of the nerves in the spine this mechanical nature of the symptoms is much more consistent with a spinal cause than with a generalized problem of the nerves the first step to treating a peripheral neuropathy once it's diagn noed is to search for a reversible cause if the person has a diabetic neuropathy then of course we should try and control the blood sugars better if the person has a low vitamin B12 or folate then we can supplement those if the person's found to have a thyroid problem then we can treat the thyroid if there's an infection then we must treat the infection if the person is a smoker then we must counsel them to stop smoking and so on and so forth sometimes a peripheral neur neuropathy is identified but a reversible underlying cause is not found in these cases we must treat the symptoms now this often means supplements and medications supplements would include alphalipoic acid curcumin and omega-3 fatty acids lots of people reach for vitamin B supplements when they have nerve issues but you do have to be careful too much vitamin B6 can actually cause a neuropathy so be careful in general enal if you don't have a vitamin B deficiency then supplementing with more vitamin B will be unlikely to make a big difference and you definitely don't want to take too much B6 prescription medications include gabapentin and pregabalin also known as Neurontin and lria which are nerve membrane stabilizers tricyclic anti-depressants and selective serotonin and neuropen reuptake Inhibitors are also used as a general eneral rule medications work better on pain burning and tingling and they work less well on numbness now we need to talk about the important diagnostic twist that I teased at the beginning of this video it's so important because it gets overlooked way too often if you've watched some of my other videos you may already know what I'm about to say because I try to talk about this a lot because that's just how important it is this thing that we need to talk about about is something called double Crush syndrome in double Crush syndrome there are two compressions of a nerve along the same nerve chain so it's sort of like a river that's being partially blocked at two spots along its course and as a result the water at the end of the river is going much slower so for example perhaps the S1 nerve is inflamed in the lower back the S1 nerve branches off and ultim timately feeds the posterior tibial nerve that goes through the tarsal tunnel in the ankle and then enters the bottom of the foot in double Crush syndrome the S1 nerve may be inflamed and the patient may also have tarsal tunnel syndrome so the nerve is then getting hit at two distinct places now this is very important to identify because failing to identify both problems may lead to wrong or simply inadequate treatments an example here will illustrate the point well now I have so many examples to choose from when talking about double Crush syndrome which again is why it's so important that patients and doctors keep this problem in their Collective Minds I had a patient a while ago that had been treated by a podiatrist for pain and tingling in the bottom of the foot now this patient had been given Orthotics Physical Therapy injections and medications and the symptoms would always get a little better but they were never completely go away and this went on for about a year the treating podiatrist wanted to surgically release the tarsel tunnel of this patient the patient wanted to avoid surgery if at all possible so he went for a second opinion from another pediatrist now that second podiatrist thought that maybe there was something else going on and maybe it wasn't just tarsal tunnel syndrome so he sent that patient to me and when he came to me with the benefit of hindsight I ordered an electro diagnostic study also known as an EMG now the EMG showed mild tarsal tunnel syndrome and also a moderate S1 pinch nerve so I then got an MRI of his lumbar spine and sure enough the MRI showed a big discernation at L5 S1 compressing the S1 nerve route so I then performed an epidural at the S1 nerve root level and the symptoms went away completely in this patient it wasn't that he didn't have tarsal tunnel syndrome he did but he also had a pinched nerve in his back if he had gone for that tarsal tunnel surgery the surgery wouldn't have helped because the tarsal tunnel syndrome had already been adequately treated the remaining symptoms that the patient was getting was coming from the S1 pinch nerve there's another story that I'd like to relate and again if you've heard me speak of this one before then I apologize for the repetition but it's so important simply because it gets overlooked so often often now this one comes from my training when I was working as a resident at Memorial slone ketering in New York City which you may know is a famous cancer hospital now many of the patients that we saw had nerve symptoms and they'd been diagnosed with chemotherapy induced neuropathies so they were being sent to us for basically symptom management the thing about chemotherapy induced neuropathies is that all you can really do is treat the symptoms with medications or maybe supplements but we didn't have a good way of treating the underlying chemotherapy injury to the nerves themselves but what we found at that time at Sloan ketering and we saw it over and over was that patients with a chemotherapy induced neuropathy with symptoms in their feet for example sometimes also had tarsal tunnel syndrome the tarsel tunnel syndrome may have been mild but when it was superimposed on the chemotherapy induced neuropathy it ended up with bad symptoms for the patient now we couldn't fix the chemotherapy neuropathy but we could fix the tarsal tunnel syndrome and once we had treated the tarsal tunnel syndrome the symptoms usually got much better even if they didn't totally go away the important take-home point is that for so many of these patients the doctors had stopped at the diagnosis of a chemotherapy induced neuropathy and they just hadn't thought to look for anything else now there was indeed a chemotherapy induced neuropathy for those patients but if they had also found a pinched nerve in their spine or sciatica or tarsal tunnel syndrome or carpal tunnel syndrome for that matter or some other nerve issue that we could fix then by fixing what we could fix we could vastly improve the symptoms and vastly improve the patients quality of life which is what we were really after for them in the end but again you have to think to look for those things and not stop at the that first diagnosis this is one of the reasons why when someone has nerve symptoms and particularly if surgery is being contemplated it's often helpful and advisable to get an electrodiagnostic study or EMG first in this study the nerves are traced out in order to see where the problem or problems [Music] are I hope you found this video on diagnosis and treatment of leg and foot number and tingling useful and if you've enjoyed it and if you've learned something then again please remember to like this video uh to help us with our YouTube algorithm also please subscribe to the channel and tell a friend who might enjoy this as well because you know that's the way that we can spread good health information and Achieve good health outcomes together now as always if you have suggestions for future videos or if you have any questions or comments for me then please leave a message in the comment section thank you very much importantly the person doing the test has to consider the presence of double Crush syndrome my colleagues and I have seen too many emgs where the doctors saw tarsal tunnel syndrome or peripheral neuropathy and then just ended the test and never interrogated the nerves in the lumbosacral spine to see if there was also a pinch nerve in the back for example now as always if you don't consider consider a problem you won't look for it and if you don't look for it you can't find it even when it's right in front of you and that can and will lead to poor outcomes I hope you found this video on diagnosis and treatment of leg and foot numbness and tingling useful and if you've enjoyed it and if you've learned something then again please remember to like this video uh to help us with our YouTube algorithm also please subscribe to the channel and tell a friend who might enjoy this as well because you know that's the way that we can spread good health information and Achieve good health outcomes together now as always if you have suggestions for future videos or if you have any questions or comments from me then please leave a message in the comment section thank you very much

Channel: Princeton Spine & Joint Center

Views: 95,276

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Id: 9TR4hVMjIzE

Length: 28min 42sec (1722 seconds)

Published: Thu Oct 05 2023