Working Diagnosis:
Right L5 radiculopathy.

Treatment:
This patient did not respond to the previously prescribed treatments of immobilization, non-steroidal anti-inflammatory drugs, or common peroneal sheath tendon corticosteroid injection. After diagnosis of an L5 radiculopathy, she was prescribed 40 mg prednisone daily for 4 days, 300 mg gabapentin nightly, and physical therapy, which resulted in significantly improved pain. Additionally, she was referred to an interventional spine clinic.

Outcome:
At the spine clinic visit, gabapentin was increased to 600 mg nightly with further reduction in pain. She was educated on the plan for referral for surgical decompression of the L4-5 disc herniation if her weakness persisted. At subsequent follow-up, she had almost complete resolution of pain and improved strength. She was able to discontinue gabapentin and successfully returned to all desired activity.

Author's Comments:
This patient had an L5 radiculopathy with the uncommon presentation of absent low back or proximal lower extremity symptoms. Given her presentation with ankle and lower leg symptoms, initial clinical focus was on ankle and knee pathologies. The diagnosis of radiculopathy can be obscure when there is an absence of axial pain and if the symptom distribution does not follow a precise dermatome. This case demonstrates the importance of completing a comprehensive evaluation beyond the symptomatic area and maintaining a broad differential for atypical presentations of common pathologies.

Editor's Comments:
This case demonstrates an atypical presentation of a common pathology, L5 radiculopathy. It illustrates the importance of performing a thorough history and physical examination as well as maintaining a broad differential, particularly if initial management is unsuccessful. Most cases of lumbar radiculopathy will improve with conservative management with prior studies indicating similar outcomes among surgical and non-surgical treatment.

References:
Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006;296(20):2441–2450. doi:10.1001/jama.296.20.2441

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