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Karen E. Anderson, DPM specializes in treating chronic pain. She has been able to solve, on a daily basis, foot pain that patients have endured for months and years. “I use a combination of a very thorough physical exam, gait evaluation and a neurological postural exam. The latter is a specialized test that helps pinpoint the source of the pain. Pain is not always experienced at the source of the problem. Even a foot problem can be manifested as back pain, and certainly vice versa.  An arthritic joint in the forefoot can cause you to disproportionately bear weight on your heel or opposite foot, causing pain in the heel or opposite foot – not the damaged joint. This is common enough that I always perform the postural test for chronic pain. Once I establish the source of the problem, I can help you resolve the pain.” 

 

Dr. Barrett 01:06 Introduction of Dr. Anderson

Dr. Karen Anderson 03:11 Describes her journey and discovery of this test

The scratch-collapse test is a peripheral exam that looks for withdrawal reflex or movement away from a non-noxious stimulus and finding a peripheral nerve.

Dr. Barrett 05:25

And without that, without that very simple, but yet elegant diagnostic test, you would have just kept floating under the radar.

Dr. Karen Anderson 05:37

You know, at 32, I wasn't sure I could continue to do my job. You know, I mean, it was potentially devastating, and have to break during surgeries, I shake my hands out, you know, and it was really hard for me to like, just do the basic things, shoulder pain, neck pain, because it it escalated over two years to almost a central nerve, kind of sensitivity, not CRPS, but really, both hands injured, both hands with the nerve entrapment and all the compensatory stuff that happened, all of which went away when he fixed the primary problem.

Dr. Barrett 06:17

No, we see that in the lower extremity. A lot of times you'll decompress one leg, and they'll come in and they'll say the other leg is better. And when I first started seeing that, I thought, wow, this is kind of wacky, but then when you know, the 10th patient, you know, that month tells you that's like, well, maybe I'm the one that's wacky, and I need to look at this a little bit more. But that's really interesting.

Dr. Karen Anderson 06:50

Actually, this was when I, when he approached me it was 1998. 2009 was when he and Dr. MacKinnon were writing together. And that's when they started calling it the scratch collapse test. That's when their joint article first came out. But he fixed my problem in 1998. And at that time, Jeff had passed away and John was kind of carrying the torch. And he was still developing it.

Dr. Barrett 07:16

Now, it obviously he had been implementing this for a long period of time before it really came on to the literature, which was about that 2009 era.

Dr. Karen Anderson 07:28

Right. You know what had happened was the evolution of this is that the two of them, orthopedic surgeons, were treating a lot of sports medicine patients, and they were like, why? If we're going to say 15, ACL repairs, you know, college and high school athletes? Why do 12 of them do really well? Why do we have three failures when the same doctors who are providing the same diagnostics with the same surgical skills, same procedures? Why did some kids fail? And so, this evolved from them looking at their failures. And they both had a background in neurological development, pediatric neuro rehab, those kinds of things. And they decided after some exam, that the missing link was a more detailed exam of the nervous system. And specifically, reflexive behavior, not subjective things like does this burn, does this tingle, you know, whatever they're looking for reflexive behavior that was outside conscious control. And they landed on motor reflexes in the scratch collapse test utilizes the skin reflex, so the withdrawal reflex, because in a in a baby until the age of one, to very gently scratch their skin, they'll withdraw that limb after the age of one, they will not do that. So, if you do very gently scratch or touch someone or do a stroke in the area of a suspected nerve inflammation and they withdraw during this exam, they're exhibiting a regressive reflex. Okay, their system is disorganized, which is a form of it when it gets really bad. That's a form of dysautonomia, but it can also happen at a very local level. And that's kind of the origin of this is the implementation of this.

Dr. Barrett 09:04

So, you point out that these two orthopedic surgeons were they were basically looking at their patients, like you mentioned, and some of them just were enabled to hit to heal, and others were, I think you called them injury prone or they were prone to many, many injuries. And so they, they were able to make the deduction that there's something wrong with the autonomic nervous system and postural it's for lack of a better way to set integrity and that if the nerve is hurt peripherally and maybe not even hurt to almost like sub clinically, right, it can disturb this process in the brain that affects the ultimate ability to balance well or helped us help us out with that.

Dr. Karen Anderson 09:55

Well, you got right on it. So, it's I sometimes you're further to this when I'm dealing with the patients is a Balance test. And I explained that it's a reflex. So, I will just gently tap their knee to a patellar reflex to get this involuntary extension of the knee. So, see, that's the reflex, and I've tapped the tendon in the same place every time I'm gonna get the same reflex. Well, now what we're going to do is a nerve reflex, but instead of smacking your nerve with a hammer like I would your tendon with a hammer, we're just going to poke or scratch and what the reason why that works is because if you have a chronic, maybe subclinical nerve entrapment, you subconsciously know to get off of that, not use it, protect it. So, you get these compensatory strategies, protective strategies. And next thing you know, your left knee hurts because you're protecting your right ankle, or your heel hurts because you're protecting the front of your foot. But if you're doing this before the nerve gets really gross, grossly irritated to the point where it's cautious. If you do this and you successfully compensate, then you're the person with heel pain that actually has more room, right? Your person with heel pain that actually has a common peroneal nerve problem, right? Because you successfully compensating it. So, they were looking for the things that were outside of complaint. Right?

Dr. Barrett 11:08

And that helps you when you're trying to look at these patients globally, and you're failing because you're just treating the tip of the iceberg and you're not looking underneath. It's like what's going on here. This is this is very elegant stuff. So, explain if you can a little bit about what goes on with chronic subclinical, maybe neural inflammation or entrapment with the autonomic system and how that how does that play? Because I thought that was really a very interesting thing were you talking about? It's a little bit different concept one year you're mentioning central sensitization, because when we talk about central sensitization, usually we're thinking more in the CRPS world, these overwhelming pain syndromes, but go into that a little bit if you can, because I think that's really interesting.

Dr. Karen Anderson 11:57

Well, central sensitization can happen in just a matter of weeks. And it can be on the spectrum just like everything else, of not very bad and CRPS. And so as long as there is a central nervous system sensitization, the other limb can be affected, they start exhibiting what looks like a lumbar nerve root compression, when actually they don't really have that just have sensitization. The reflexive behavior is a centrally acting and centrally occurring phenomenon. Your brain is involved in reflexes, the attendant the, like patellar tendon reflex occurs at the spinal level, but proprioceptive reflexes occur at the reticular system level, that is brainstem, and it requires input in order to know where you are, are you upright Are you about to step off a curb? Are you oriented to gravity? And if you're getting, if you have a nerve impingement, that nerve is not conducting correctly, if it's not conducting correctly, then faulty information is going to your system for balance the reticular system, and then you start getting higher order coordination complications. So those are the kids that are always injured, they can't recover from things because the central nervous system is responsible not only for incorporating all that information, balance strategies and behavior, you know, motor behavior, but also protective reflexes, also, regulation of healing, autonomic nervous system is how you regulate healing, how you mobilize white blood cells, right and blood flow. And so even those things don't work. That's one of the reasons when I was still operating, I would do this test before I'd operate on somebody, I'm not going to do that hammertoe procedure, until I've sorted out that nerve right next to it, if they fit and reflex for that, because I want the autonomics to be intact. So, they would get blood flow and white blood cell response and all that.

Dr. Barrett 13:54

Very interesting. And sometimes if you can get tripped up very easily, especially in a very busy clinic situation where you know, you're in the belly of the beast, and, you know, they come in for one problem. And it's just by default for this particular thing. But if they took maybe this one extra step of including this in their in their physical examination, it might bring this this light on that says, oh, wait a second, I might have to look at something else here and figure out maybe this is a symptom of another problem, a compensation, which I think is going to help them from an accuracy of diagnosis, obviously, but improving the outcome. I mean, you're gonna get a much better outcome when you figure out what really is going on versus throwing a dart in the in the dark.

Dr. Karen Anderson 14:43

Well, that's a pretty good segue for a brief PowerPoint if you like.

So basically, it is called the scratch-collapse test. And it is a fairly literal description of what happens. So, this is a peripheral nerve exam, using these pediatric or primitive reflexes that I was talking about, to localize the suspected nerve entrapment, either prior to an elective surgery where you're going to be, you know, screening a patient for risk factors for not healing, or do they have what are more sensory findings where you know, there's a nerve problem, and you just want to localize it. But primarily in day to day, it's used as part of an overall exam, just for heel pain for forefoot pain, plantar fasciitis, Achilles tendinitis, whatever I'm gonna incorporate this in. So, it's been known by several things, Dr. Beck used to refer to this as the PANE. That's what I referred to it in the chapter you're referencing, if you go on YouTube, and you do scratch-collapse test, there's, you know, countless videos for it. That top one, by the way, is the one where I really expound on it. And it's a really basic thing. So the idea is that you do a baseline test, the examiner has the patient sitting on an exam table with their feet off the floor, the elbows are tucked in, in this neutral position, elbows bent, and you just put a little resistance against the patient's hands and then very mentally accelerate, just to the point where you can determine that they can keep up, then you do a light scratch, and what must be a non-noxious, non-sharp, stimulus, to you know, anatomical structure that you're testing. And if that, if that person has a problem in that area, they're gonna have this momentary fail. And we use this for recalcitrant musculoskeletal problems where patients have been seen by other people and not gotten any better, or they've had this problem for a long time. And try to figure out if there's a nerve involved.

Dr. Barrett 17:29

Let me interrupt here, because I want to make sure everybody's clear on it as well as myself. If you can go back to that one slide where you're, you're doing the scratch. Now, are you, let's call that the provocation, although it's not a painful provocation, but it is a provocation. Are you trying to put that provocation into the area where you suspect the entrapment?

Dr. Karen Anderson 17:53

No, it’s a checklist? So, I'm gonna go boom, boom, boom, we're gonna start to come and peroneal, for example, I'm gonna go come superficial, do several poster tip, I'm going to just do a checklist. And I did the same way over time.

Dr. Barrett 18:31

Is that usually ipsilateral? Or contralateral?

Dr. Karen Anderson 18:34

It depends. So usually it's ipsilateral. There are one or two tests that are contralateral. Okay, usually an upper extremity, but there's one in the lower extremity, like for deep peroneal nerve. But it's very, you know, this is where getting used to doing the test a million times. You start with the first step and keep doing it, you'll figure out what the patient's real resistances. Okay, so there's a peripheral exam and a central exam. The peripheral exam is what I just showed you the central exam, we're not really going to go into a whole lot here. It's kind of outside the day to day use of it. But there is a way to look for people who might be closer to something like CRPS or dysautonomia, by using a different set of tests and the YouTube I alluded to has that but we're gonna stick with just a peripheral provocation. It's already been tested. Dr. MacKinnon has been working on this for almost 20 years herself as half her fellows and it actually compares very favorably to other ways of testing. So, they're almost 200 patients with who had positive nerve conduction. There were also additional tests that you do for nerve like tunnels and neural tension test and the scratch collapse test comes out very favorably. The as I mentioned, you can use it to localize where exactly am I going to do either an ultrasound guided nerve block or a surgical decompression because you can literally walk marched along a nerve, and determine where it's the most likely where it elicits the reflex. And that's we're going to target treatment. So, localization.

Dr. Barrett 20:08

So, can I interrupt you a second? Because I thought your pictures were really, really very good there where you were in the clinical, with the gentleman setting there, and then you were provoking the medial aspect of the ankle, presumably the tarsal tunnel, would you say, All right, I want to see where this nerve is potentially entrapped? Because we know that typical tibial nerve can be entrapped in several areas, as well as its bifurcation, the medial plantar lateral plantar, would you start proximately, at the distal medial gastroc soleus. And then move distally. And like, one provocation, and then and then test the arms? And that's how you would localize it?

Dr. Karen Anderson 20:53

So, the responses the reflexes momentary, you only have a few seconds to elicit the response, either pass or fail. And you would start at the top of the tarsal tunnel, more about the flexor retinaculum, I don't really go up into the muscle unless I'm a little more suspicious about pathologically tight calf, he coined his gait, you know, something that I suspect might be more proximal. And even in the context of including this in your day to day exam, you have to limit your range, initially, for the most likely areas of entrapment, okay, and then move out from there if you're not finding it, but in this area, where I'm poking right now is about the midpoint. And then if it has, I would still especially if its plantar fasciitis, I would definitely go to the porter fetus, and more into the medial foot and test there as well. So

Dr. Barrett 21:46

One other question comes into mind here. When do you implement this testing in your physical exam? Is this one of the first things you do? Or is it after you've got kind of dialed in an idea of kind of what's going on, and then you want to kind of zoom in on that one area of anatomical entrapment.

Dr. Karen Anderson 22:05

So, I'm going to do a detailed history, because I always find things like, Oh, you broke that ankle six years ago, and things like that. So, I want to deal with history, then I'm going to do a motor muscle strength test dorsiflexion plantar flexion, every direction, major and minor groups, and that often points me in the right direction, because I will often find a unilateral weakness. And that will kind of target me because you do have to see however many patients you're going to see that day, right? And so, if you can zero in on it, by looking for motor weakness, that really speeds it up.

Dr. Barrett 22:38

Okay. So, you've got, you've got a pretty good sense of what's going on. And this is now allows you to put the Knightscope on it, so to speak, and see what's really going on.

Dr. Karen Anderson 22:49

Right, and it's very demonstrative to the patients because they can feel when they fail a muscle test. And they totally feel it when they fail this test, because it's so unfamiliar to people it's like, they don't even know what's coming. So, it's not like they can fake it or, you know, try to second guess it. They've never seen it before. Right. So, it gets to the point very quickly.

Dr. Barrett 23:10

That takes that placebo question out pretty quickly.

Dr. Karen Anderson 23:14

Yes, it's very hard to fix this thing. This test. I mean, I've actually had attorneys asked me to do this kind of screening test and someone who fails, everything is probably not really participating. The tendency is to resist when you're asked to resist, okay? Alright. So, one of the things about this in that vein is number two, it is a systemized pattern, regardless of the chief complaint, I do it the same way every time. Okay. So, this degree, if we take this and add it to a typical exam, diagnostic imaging, diagnostic injections, and we add this test, we're much more likely to do a comprehensive exam. So, I'm actually I have an abbreviated version of this, I'm going to actually move out of this for a second and scoot down. Because this could get really long really fast. Okay, so one of the things that one of the reasons this exists is because there were problems to solve, why were we failing, what wasn't working, we had these problems to overcome. Typically, the patient is giving you the chief complaint, and that directs your search, but that's allowing the patient to give you a complaint and you base it only on that. The other problem is that techniques that are used to diagnose are the same for acute and chronic and that's not appropriate. It ignores number three compensation. You cannot rely on just what the patient is telling you for looking for the problem because the pain is not necessarily what the problem is because we compensate our game and the other problem is that most musculoskeletal exams ignore the nervous system unless someone is complaining of burning or tingling, complaint-based medicine is limiting. You're asking the least experienced person in the room to tell you where to look. Okay? And a checklist overcomes bias. So, there are wonderful books and references about this. There are various types of tests that are already in mainstream medicine that are checklists. And this is a checklist. So, you do your physical exam, you do your imaging, you do an evoked pain response, like if the tendon the Achilles tendon is sore, you know, you're going to palpate that and examine it and all that. But a lot of the time, that's done within some assumption that there's a functioning nervous system that as a faulty assumption. So, what might you find on a scratch collapse test pretty much an adrenaline or irritation of any peripheral nerve, and interestingly, is periodically on the contralateral limb because someone is so successful at compensating their gait, that their symptoms are not where their problem is. So, in that, if you're ready for an example of that, I have a video for you that I can share with you. Absolutely. All right. So, this over here. So, this is a patient who was sent to me, she had been symptomatic for years, she had been seen had neuroma surgery twice. The second time, supposedly, there was a bursa, she would get some relief from that, but then kept getting more and more pain as she kept getting put into a boot and then physical therapy that didn't work at cetera. Then she had an MRI finally, and it showed this occult fracture of the keyboard. And then she got put into boot again. So, she spent the better part of a year in a chemical boot and not getting anywhere. And her physical therapist has sent her over. And the following. And I'll narrate for if you can't hear. So, can you hear the audio on the video? No. So go ahead and narrate it for me. All right. So basically, we're going to start with an example of the left lower extremity, because we've already targeted where her symptoms are, its unilateral pain. So, I'm going to make a detailed but focused exam here. And as always starts with a baseline test, which I'm going to show you.

Dr. Karen Anderson 29:09

The important part is to have them meet your resistance and then accelerate lightly to see if they can keep up. That's the difference between just shoving somebody's hands together, which is overpowering them and actually doing the test correctly.

Dr. Barrett 29:23

So, when you say accelerate, what you're talking about is a slow acceleration where you're just not trying to overcome

Dr. Karen Anderson 29:33

That’s right and the whole balance test. The whole baseline takes about three seconds. You can't do this forever, because then someone's gonna fatigue. Gotcha. Now we're gonna start the provocation. We're basically gonna march down the perennials and then do I believe webspace.

Dr. Karen Anderson 30:33 Continues explaining the case

Dr. Barrett 32:09

When you initially checked her out for her superficial peroneal was she also manifesting some Sural at that time?

Dr. Karen Anderson 32:18

No, she didn't. And I think it's because we prioritize and there's only so many things that you can cope with at one time, and that your body's gonna do like, how many times have you heard a patient got their right knee replaced? Because the left one wasn't bothering them. Nine months later, they're like, Oh, my God, my other knee, you know. And so, you know, you can have simultaneous pathology going on and one of them is just you know, barking the loudest.

Dr. Barrett 32:43

Well, the reason I asked you that Karen is because it's so common in peripheral nerve surgery, I oftentimes will refer to the patients as onions, we'll pull way that first layer, it's real bad. We know it's bad, because we can see it. And they'll get better. But all of a sudden, they'll say, Oh, I've got something other in this other area. Well, you know, there's a lot of Neurophysiology that goes on, but they these patients can mask themselves.

Dr. Karen Anderson 33:11

True, true. And you know, one of the things I remind people is that when you sprained an ankle, broken an ankle, metatarsal fracture, the force that's required to break bone can cause traction injuries on nerve, especially if it's an inversion injury, and it can cause the edema and the fibrosis can entrap the nerve. So, it's not when you break something, the bone is not the only thing evolved and it's hard sometimes to remind people of the physics of that kind of trauma,

Dr. Barrett 33:40

And then the other the other premise everybody has to remember it's it doesn't take a lot to hurt a nerve. It can be a very, like almost seemingly non-existent injury and it can be devastating for people.

Dr. Karen Anderson 33:53

Absolutely is the most sensitive tissue, right. Alright, so we did do an ultrasound guided injection. So, we did this from two planes.

Dr. Barrett 35:19

I mean, pretty close to 100%, if you're blocking the nerve that seems to bother them, and then after you put that block, and that that reflex dissipates or disappears…

Dr. Karen Anderson 35:31

And additionally, there some symptoms improve, for example, I sent that patient is back to her physical therapist and also off to she went to a chiropractor as well, and did really well with Sorry, I'm trying to get back to the main screen. Oh, here. And so she did quite well. I think if you click on that other tab there, yes, stop feeling. So she did quite well. In fact, she is, you know, still seen the physical therapist in the chiropractor and you know, she did have a trauma. Actually, I had images of her MRI as well, she actually had not only evidence of persistent edema in the cuboid, but she had disuse, osteoporosis, the radiologist read the report as being marrow edema in every single visible bone in that image, and she'd been in a boot for six months. And what's interesting is the MRI shows the structural problem, but as soon as you solve the functional problem, she went back to exercise, she got a boot. She went back to doing everything.

Dr. Barrett 36:42

That's why MRIs are, you know, they really can tell you a lot sometimes and then sometimes they tell you nothing and people will say well, you know, why didn't the problem show up on the MRI and it's because it's just not a sensitive enough test, even though they are fantastic. And that's why, you know, I talked to one of the gentlemen that lectured at the ANS meeting about the Sigma 1 imaging combined pet MRI. Oh, yes. Yeah. So, they're, they're, you know, the radiologists even acknowledged that MRI is really kind of a poor modality because all it can show is morphology or morphology changes. It doesn't tell you where the pain is coming from. And I mean, shoot, you go across the street to the grocery store and you line up 100 people randomly 55, 60-70 who knows are going to have abnormal MRIs, but they don't have a day of pain. So, you know, the doctor?

Dr. Karen Anderson 37:42

Dr. Beck used to say an MRI will tell you what, but it will not tell you why.

Dr. Barrett 37:46

Yeah, exactly. For sure. So, is there any particular areas in the lower extremity that seem to be a little bit more blessed by the accuracy of this test, or less blessed?

Dr. Karen Anderson 38:01

Well, one of the things that happens periodically, is that when someone's been lumbering around with this for a long time, they actually have compensatory issues that have resulted in back pain, core weakness, and it's very hard for them without any core stability to pass the basic tests, they look like they fail everything. So, one of the reasons I seat people, the way I do is because I can put like a little support behind their back. And because this is so sensitive and so subtle, that all they have to have is the impression of some support behind them contact behind their back, and then I'll actually start the test over again. Because if I don't trust the findings, that doesn't jive with their symptoms or gait, right now, I'm going to assume that they've deconditioned, or they've got the central nervous system position and lumbar spine is weak, given that it provides all the nerves of low extremity. So, I'll just support that. And then, you know, test again, I will say that when patients have any diabetic neuropathy, or sensory neuropathy, it's very hard to do the test because they have to perceive the provocation. So, this works best in people who do not already have profound sensory loss.

Dr. Barrett 39:09

Yeah, that makes a lot of sets, for sure.

Dr. Karen Anderson 39:11

There are there's limitations to every procedure, every exam. This is no different. There's there are limitations to this as well. There are times where if someone I think is really on the precipice of CRPS, there's no way I'm gonna stick a needle in that person. So, I have them start some Gabapentin and do that for a month. I have a very interesting case when to type out that. I did reverse CRPS it was active CRPS. And there's no way I was going to inject that guy until he had his lumbar sympathetic block first, right. So, we did that, which kind of, you know, wipes the slate clean for a little bit. It kind of clears some of the you know, did something to the dysautonomia, or nerve sensitization for a while, then I can trust that test. So, the weaknesses are really more about the condition as opposed to one individual nerve or another.

Dr. Barrett 39:58

Yeah, and I would imagine what's somebody with high you know hyperalgesia in anything that touches them is going to fire them off. So, it would probably be not a very good test in that situation because the, the, the canvas that you're trying to paint on is not receptive to the paint.

Dr. Karen Anderson 40:15

Exactly it but there's alternatives so I can make an orthotic correction for that pathology. I can do a transdermal medicated cream if you want to, I can show you a slide about that. So, if the share screen again, to show you a few things, if there is an alternative, it would be something like transdermal medicated creams. So, if I'm not going to do the Lidocaine block, I may do a transdermal medicated cream that has ketoprofen 20% and cortisone 2%. And it's compounded. I have them use, just an eighth of a teaspoon over the area and do a very gentle nerve mobilization kind of massage. I can make orthotics that help these things. We all know that a metatarsal pad helps them more it's neuroma. So, let's just do that. And do kind of a flexible device. See if I can advance this. Okay? The pros and cons of this include the fact that it's objective, you're not getting the patient to say, oh, that stings, or Oh, that feels better or that burns. It really only takes a few minutes. I mean, you saw how quickly we could rule out and localize the nerve for the patient in question. It does tend to solve pains faster, because you're looking at the next system that hasn't been examined. And the special equipment, I mean, if you're going to do an ultrasound guided injection, fine. But because there's things besides injection like orthotics, transdermal cream, physical therapy, etc. You don't really need any special equipment. It does take a little while to learn. But I've even taught people this remotely, a young lady in Maine, read the chapter in your book. And she contacted me. And this is mid pandemic and we weren't traveling. And I said here, I'm going to send you some educational materials about this and videos, and she really picked up on the whole maneuver, then we did some zoom appointments where she would have a patient in front of her. And I would guide her say, Okay, well, evoke here to do it here. And I can't even know how she did the resistance test. And she now knows how to do it. And she had been doing it a year before we ever met, we eventually finally got to work together. So, while it's there's a learning curve, not only is it possible, but it's even possible remotely is I tell people it's a skill, not a pill, you know, so it takes a little bit of work and the research on it. It's so new, that the research is a little limited, because someone is not necessarily trained. I read one paper where a group of residents were brought into the room to do this test and they found it to be meritless. Well, let's because it was unpredictable results, right? But it was probably unpredictably applied. You wouldn't ever have someone you know, come in from a clinic and say Here try this surgery. Right. Right surgery worst right now. So, you know, it takes issue sometimes with a poorly applied technique. But when it's applied, it's pretty amazing. I have, you know, a couple other examples of pre and post injection to watch.

Dr. Barrett 43:25

Let's see them because I think these examples are really they're illustrative of the whole concept.

Dr. Karen Anderson 43:33

Alright, so you mentioned get to my screen here. Oops. Okay. So I do neural tension tests of a sort. And this, this is really important. The reason why some of these tests work is the concept of inhibition. Dr. Beck and Dr. Bronson identified weakness. Weakness is a symptom, not just pain, not just limping. Weakness is a symptom. And sometimes what happens is patients avoid movement or tension on an area and when you find it by doing this test, and block it, their strength comes back. So that's what this is about. And if you can't hear it, let me know and I'll narrate okay.

Dr. Barrett 44:22

Yeah, go ahead and narrate for us if you would.

Dr. Karen Anderson 44:23

So, this is a neural tension test for more neuroma. And what happens is the nervous plantar, and in a position where hyperextension like this, there's tension on the plank owner. And for some people, it's so irritating, they can't maintain that position. So, there's the affected foot and the unaffected foot. And when I stop talking, I'll actually advance this a little bit. So, she can do the test here. Okay, she couldn't resist that. She can't. So now at times, one would say, oh, that must be peroneal. Because it looks like motor weakness, but motor weakness is also inhibition. And what's inhibiting her is the plantar nerve. It's so irritated being extended like that, that she folds to a place of relaxation. So, the misconception is motor nerve function. This is proprioceptive and sensory nerve function, and the reflexes are, in this case, 180 degrees. So, here's what we're going to do, I'd already done the scratch collapse, I'd already ascertained that it was more in the third space.

Dr. Barrett 46:11

So, let me ask you a question. Because I want to be clear on this before you put that right foot into the tension position. Yes, she had more ability to fight plantar flexion of her digits. Or not?

Dr. Karen Anderson 46:23

I didn't test that one, but routinely, what'll happen when a patient is sitting in these exam chairs, hamstrings are straight calf is straight, they're in a position of some degree of tension or lumbar strain. For some people, not all, if they have, if they fail that test, I'll swing the legs over the side and take the strain off their back, take the strain off of the knee. Right? And just again, sometimes that will be yay or nay. You know, like, it'll be worse when they're extended and veterans are flexed. But usually if their back of their knee is involved.

Dr. Barrett 46:56

Okay, so for my understanding, you're not necessarily seeing because I would presume that if I had somebody with a hot third interspace, and I make it more hot with the tensioning that that would even be more of a inhibit, there would be more inhibitory effect going on. Do you see that? Or am I just trying to barking up the wrong tree?

Dr. Karen Anderson 47:26

Context matters. So, in this position, when on the left foot, she could do it and the right she couldn't run willing to accept that as this is the problem. And it actually just confirmed the scratch collapse test. It did a few minutes before.

Dr. Barrett 47:41

Okay. All right.

Dr. Karen Anderson 47:45

So, we've already done the injection, there's local and the 1%. Works pretty quickly. And futzing to get the local some time. Gotcha. So now we're going to repeat the study. So, there she is doing it on the asymptomatic and now she can resist because her brain doesn't think there's a problem there because it's not. Right. And,

Dr. Barrett 48:13

And that clearly has nothing to do with common peroneal. Correct? Well, let me rephrase that. It does from an inhibitory status, but it doesn't from a motor status. Right?

Dr. Karen Anderson 48:27

Right. And that, you know, there's just so many examples. I even get surprised sometimes, you know, like I, as I said, the nervous system is a system. And as you said, you're peeling the layers of the onion. So sometimes you'll block A and then they'll have the patient walk, for example. And after this, I'd say okay, well, let's have you walk in, okay, my heel pain is 50% better? Well, I'm gonna take off the ultrasound look at the plantar fascia and say, Okay, well, you have two problems. You have the plantar fasciitis, which is your chief complaint, and failed the nerve tests, we block that and you're 50% better. The ultrasound shows a lot of fibrosis, possibly edema and the plantar fascia chronic changes. Well, there's nothing wrong with doing the cortisone shot in that as well. Or you want to make sure that the orthotic you're doing compensates for that as well, because they have compensated for so long. They have these combined problems for so long, that you must treat everything you find. So, find that. It still hurts on their heel, when they walk after that test. It still hurts when you palpate it great.

Dr. Barrett 49:30

However, there are some cases where you go find the primary generator, and you take care of that. And the other ones just subsequently, they just body takes care of it. But yeah, you're right. If there's a musculoskeletal degeneration because of this process of compensation, you're probably going to have to take care of that as well.

Dr. Karen Anderson 49:51

I have this thing on my phone where I'll stop myself in the middle of exam. It's like, you're going on the list, because I'll find something and we'll do the nerve block or do an orthotic accommodation and suddenly like the symptoms are improved. Now I'll pause and say okay, well, I'm gonna add it to the list. So, some examples of that and be an expert at zoom by the time I finish this. So, this is what I call interesting patients. I will expand this a bit so you can see this. So, I get surprised all the time. By things that work. So, this patient broke her toe, and it appeared to heal without incident. Can you see what I'm talking about? You see my screen?

Dr. Barrett 50:43

Yeah, I see your screen very well.

Dr. Karen Anderson 50:44

So probably six months after her injury, her toe fracture, she started developing heel pain. And it was worse than the toe off phase of gait, which is you know, part of a gate exam that we would hopefully do. cushioning the area that was symptomatic didn't help X rays of the hill were fine. But she had a nerve entrapment on the scratch collapse test immediately adjacent to her fracture. So, we took pressure off the nerve, I skipped laced her shoe so that there was not a tight lace on the top of the nerve. And I put a pad a Morton's extension in her shoe that basically treated where the original injury was, and 80% her pain was gone. And I changed her shoe in her insert. And that was it in just a moment. And then, you know, this patient had a sick patient had arthritis, and X ray shows moderate disease, but he has severe pain. Well, he failed a nerve reflux test for the nerve between the areas of arthritis. And in his case, we did a cortisone shot and metatarsal pad to take pressure off the forefoot and, you know, with the persistent arthritic joint, this pain went down 70%. So, there's just I mean, case after case, you know, there's, there's just so many things. So, this patient had calcaneal fracture, and had a lot of pain. And one of the few things that really gave them some relief was treating the deep peroneal nerve because he'd had basically severe damage throughout the entire foot of patients where we treated the nerve. And when there's within a few days, her screaming heel pain had improved. And she was already doing orthotics and all that too. So deep peroneal nerve is a really, really common one. It's not one that patients often complain, I have cramping on the top of my foot. Well, this because they had a compression irritation when the deep nerve I have, I don't think this one's in here. But I have one where a patient had a first mp joint implant. And it was beautiful on X ray, and the doctor was really happy with the result, but the patient was not. And so, his physical therapist sent him over. First time we present it, he failed the test for the peroneal nerve, which makes sense, we just had this you know, join it the first mph or procedure at the first mp joint. And that seemed fairly logical to test for it out I did a little nerve block in there and two weeks and orthotic adjustment. Two weeks later, he wasn't much better still had a little bit of we had quite a bit of resistance to motion of the joint gait was still compensating, he was not getting off this first mp joint. And it would look like this surgery failed even though radiographically was beautiful, right? So, it just did it again. And this time, it was superficial peroneal nerve, well, multiple ankle sprain or been in the boot after surgery for some time. And probably got from those conditions, some traveling around the superficial peroneal nerve ultrasound, we'll even show you some times where the proximally the nerve is more elliptical, where the area of interest is you'll see a little compression on the ultrasound, and then it'll be normal again, distal. So that more out on ultrasound, and we just did the 100 dissection with local and steroid right at the area looks compressed until you see the fashion move away from the nerve. And week later he comes in and his comment was you hit it out of the park, you know so basically now that first impeachment functions, it will he can move forward off of it he can go back to doing what he wants, and it basically salvaged a perfectly done surgery. Yeah,

Dr. Barrett 54:31

And that happens all the time. You know, that deep perineal nerve just doesn't have anywhere to go. You got a couple millimeters between the bone and the skin and I mean just the I mean even if someone does have been inactive and they do a perfect dissection, just the swelling postoperatively can be enough to put that nerve into a into a problem. It's a nerve that just doesn't have a lot of forgiveness and just anatomically speaking, but, you know, that's a great point.

Dr. Karen Anderson 55:03

The anatomist that lectures a lot at AENS once described a very small capsular branch to the second MP joint off of the deep corneal nerve. Let me tell you how many times someone comes in to tell me I have a second interspaced in aroma and I know that that's what that is, and it hurts right there, you know, or they think they just have bursitis. And maybe they have a long amount of tarsal. And everything that you've done to help that has not worked. Keep in mind that there is anatomically a small capsule and branch off the deep cranial nerves. So, I've had so many patients who failed treatment when it's approached as a second interspace neuroma, because no one was looking at this right.

Dr. Barrett 55:46

Now, that's, that's a great point, what's one of the biggest barriers to entry because, you know, I mean, this is an important test, it's certainly a bullet that you would want to put into your armamentarium and the diagnostic world what why I mean, I know medicines, a slow boat to turn, but but we're looking at, you know, 20 plus years here, or more. I mean, maybe last year, if you say it was published in 2009 2010, and whatnot, what's one of the big barriers to entry here?

Dr. Karen Anderson 56:21

I would say the doctors really need to spend time doing this. And if it can't be mastered in a weekend, then there's a little less acceptance of it. And unless you value this as something that can be the game changer that it is, it's hard to put in the time constant that having said that, I've had someone learn it remotely. And I've had people pick it up in a weekend. And the trick is really like making sure that you do the resistance test correctly. So, what I've started doing, including with the doctor in Maine, who learned this from me is I will send some instructional information. So, I have a Dropbox full of videos to show you the techniques. So, like anything else, you know, you can watch this, you can practice, you probably want to get pretty comfortable with it before you start injecting things. But it's really not that it's really not that hard, and people perceive it as such. So, like anything else, if you're willing to practice it, you can get good at it. And I have condensed it down to where I can really teach someone how to do this very quickly. Right?

Dr. Barrett 57:32

Well, it's kind of like ultrasound. You know, when you make the commitment to put ultrasound into your practice, you're not an expert at the first day of that, in fact, you're probably not an expert on the 10,000 today. But the point is, is that you have to integrate these things into your practice, so that you can become more adept at them.

Dr. Karen Anderson 57:51

I do try to get some agreement, like when I lecture on this, I'll try to, you know, get one person in their community to be the expert at it. And I'm like, Okay, I just need this one person in this community, right? Take this on and learn it, because then they can teach it to other people who are interested. Not only that, I am the person in my community that gets these weird cases, and this didn't work well. And this surgery failed, or they've had all this therapy, nothing's working. I'm that person. Well, you just need one person in that community. And that can be your diagnostic go to. So then all right. Next, I'll say okay, you know, you did a great surgery over here, I'm going to send them back with this simple little adjustment. I'll send it back to their primary say, Okay, you need to do a spine workup? Because it's not the foot, right, you know, so. So even if I can get one or two people in the community, to be that touch point, it can help 1000s of people.

Dr. Barrett 58:40

Well, it's kind of like I joke with my partner, Dr. DuCasse. And, you know, that we're those ugly little fish that swim at the bottom of the aquarium that tries to clean up everything else. And most of the time, it's, it's not because it's such rocket science. It's just because you have the eyes to look in that direction. And you can save these people a lot of heartache. And you know, a lot of times they're down the rabbit hole that had 15 MRIs, and God knows how many surgeries and all this other stuff. But then somebody looks in that one closet that's never been looked in as like, Oh, there you go. But I think the beauty about this is there's no capital expenditure for it.

Dr. Karen Anderson 59:26

This is true. And sometimes I think that's one of the shortcomings, this is still not a pill. So, there's not like this, you know, capital investment and training either, right? You know, there's not like this drug company or device company that's gonna say, you know, let's spend $50,000 on a seminar and, you know, so there's, there's really grassroots and and it's acknowledging that there's part of the nervous system that's not getting checked every day in and you would no more ignore hemoglobin A1C, right before surgery. Why would you ignore the postural part of the nervous system? Right, you know, we

Dr. Barrett 1:00:15

Well, and I think there's a lot of intrinsic value to things like this. Because when you're able to make a diagnosis and help somebody out, that is a measurable karma return, that this is the juice of why we do what we do. And so I would encourage everybody to really look at this, because they're gonna get that feeling in the clinic, like, wow, I just figured out something that's a cool feeling, you know, and that makes that patient better. And that's even another cool feeling. Absolutely.

Dr. Karen Anderson 1:00:49

Because everybody has that patient, they dread, how am I going to fail to help this person today? Right, and Alec, exactly. This overcomes that on a daily basis, and, you know, the way that medicine is going, and it's so, you know, compartmentalized and commoditized, that, you know, you can be a cog in the wheel, right? Or right, or you can be the hub. Exactly, you know, and you can be the reason why it keeps turning. And, and, and actually, you can set yourself aside, and outside of some of the constraints of the usual day to day mill, because you've got this technique that nobody else is willing to take on, you're going to solve a lot of problems. And you're going to attract a lot of business and a lot of grateful patients, right?

Dr. Barrett 1:01:32

Yeah, no, it's wonderful. Karen, thank you so much. I, I love visiting with you on this. And I'm going to make a dedicated effort now to really start picking this up a little bit more, because I think it really is kind of like some frosting for the cake, you know. And so, thanks so much. If people want to get a hold of you, what's the best way to reach out to you on your website?

Dr. Barrett 1:02:55

I'll try but I think it's I think there's some very valid reasons why I want to get this into our day to day because I think it has a lot of merit, and it could help us pick up a few things more. So, I really want to thank you. And, and this was very, for me, it was very educational, and I appreciate it so much.

Dr. Karen Anderson 1:03:15

Well, thank you very much. I really, really enjoyed talking with you about this.