Intermittent claudication symptoms, following extended surgery in lithotomy
position, normalised by Connective Tissue Manipulation
Leon Chaitow ND DO Honorary Fellow, University of Westminster, London
History: A 65 year old male presented with intermittent claudication (IC) symptoms,
affecting his left calf area, of 8 months duration. Onset had occurred 24 hours after 3
hours in lithotomy position (Candy-Cane support) during ureterorenoscopy to remove
stones from his right kidney. Subsequent to an unremarkable recovery from the procedure
he reported that the next day he was unable to walk more than 50 metres before onset of
tingling discomfort in his left foot, a burning lower left calf sensation, followed by a
painful calf cramp, relieved by several minutes rest, but recurring after walking a similar
distance. Prior to the surgery there had been no symptoms relating to walking for even
long distances. There were no cardiovascular health issues.
The medical diagnosis was of IC, however tests, including ultrasonography, were normal.
No treatment apart from use of analgesics had been suggested.
A comprehensive examination produced no evidence of circulatory, neural, or orthopedic
dysfunction, apart from bilateral hamstring and TFL tightness. He was able to exercise
(brisk walking or marching on the spot) for only 35 seconds before the onset of all
symptoms as described above.
Hypothesis: Compression during the lengthy period in the lithotomy position, may have
traumatised the superficial fascia. Cohen & Hurt (2001) note that muscles, vessels, and
nerves of the extremities are confined in fascial spaces and potentially exposed to
[compression] injury. Alternatively cutaneous obturator or lateral femoral nerves may
have been traumatised, inducing onset of symptoms.(Litwiller et al 2004)
(Figure 1)
Schubert (2008) reports “stretching, compression, and double-crush
injury”; while the burning quality of pain suggested fascial involvement.(Ebner 1975).
Local assessment findings: Palpation in the region, compressed when in the lithotomy
position, revealed marked reduction on the left in the potential for skin to slide/move on
underlying tissues (McCarthy 1998), as well as a marked resistance to skin-rolling,
suggesting subdermal dysfunction.(Pohl 2010). The most probable neural involvement
was the medial sural cutaneous, that descends between the two gastrocnemius heads, ,
piercing the deep fascia, joining the common peroneal, to form the sural nerve.
Treatment and outcomes: 8 treatments, 2xweekly, to the tissues of triceps surae and
gastrocnemius, using mainly Connective Tissue Massage, supplemented with Myofascial
Release, and Muscle Energy Techniques, resulted in the patient being asymptomatic
within a month. This improvement has been maintained for 12 months.
References
Cohen S Hurt W 2001 Compartment syndrome associated with lithotomy position. Obstetrics &
Gynecology (Part 2) 97(5):832-833
Ebner, M 1975 Connective tissue massage. Churchill Livingstone, Edinburgh
Litwiller J et al 2004 Effect of lithotomy positions on strain of the obturator and lateral femoral
cutaneous nerves. Clinical Anatomy 17(1):45-49.
McCarthy M 1998 Skin and touch as intermediates of body experience with reference to gender, culture
and clinical experience. Journal of Bodywork and Movement Therapies 2(3):175-183
Pohl H 2010 Changes in structure of collagen distribution in the skin caused by a manual technique J.
Bodywork Movement Th. 14(1):27-34
Schubert A 2008 Positioning Injuries in Anesthesia. Advances in Anesthesia 26:31-65