Toe Sensations: Possible Nerve Issues and Disc Problems

Toe problems

For several months, there has been abnormal sensation on the inner side of the second toe of the left foot, with a dull feeling.
Occasionally, there is a slight tingling sensation in the ball of the foot and the base of the big toe.
Initially, the orthopedic specialist suspected a herniated disc due to narrowing observed at L5-S1 on X-ray.
After undergoing six to seven sessions of physical therapy focused on lumbar stretching, there was no improvement.
Subsequently, the rehabilitation specialist performed tests for herniated disc movements (forward bending, backward bending, leg raises) and found no abnormalities, nor were there any significant lower back pain or typical sciatica symptoms.
Instead, it was noted that the muscles on the front and back of the calf were very tight and prone to cramping, and there was also evidence of medial wear during walking, raising suspicion of peripheral nerve compression.

I would like to ask the physician the following questions:
1.
Can a herniated disc at L5-S1 present with such isolated toe sensory abnormalities?
2.
If the symptoms of a herniated disc are not prominent, what locations of peripheral nerve pathology should be considered?
3.
Based on the symptoms described, should the focus be on a herniated disc, tarsal tunnel syndrome, or other conditions?
4.
If an MRI is performed, can it be arranged to scan from the lumbar region down to the entire leg to identify the point of nerve compression? Thank you.

Wang Shaojie, 30~39 year old female. Ask Date: 2023/12/12

Dr. Jiang Junyi reply Neurology

Dear Ms.
Wang,
You mentioned, "If I undergo an MRI, can it be arranged to scan from the lower back to the entire leg to find the point where the nerve is compressed?" Generally speaking, peripheral nerve compression can often be diagnosed using electrophysiological studies.
Nerve conduction studies assess the conduction velocity and waveform of large fiber nerves.
Electromyography (EMG) evaluates the muscle response in the area supplied by the nerve, which can help localize the site of nerve damage.
I recommend that you visit a neurology clinic for further evaluation, where you can consult a physician specialized in peripheral nerves, as they have more experience with EMG testing.
Thank you for your inquiry, and feel free to discuss further.
Wishing you good health, peace, and joy.
Dr.
Jiang Junyi, Department of Neurology, Taoyuan Hospital

Reply Date: 2023/12/12

More Info

Understanding toe sensations, particularly when they involve numbness or altered feelings, can be complex and often requires a thorough evaluation of both the spine and peripheral nerves. Your symptoms, which include numbness on the inner side of your left second toe and occasional tingling sensations in the forefoot, suggest that there may be an underlying nerve issue. Let's address your questions one by one.

1. Can L5-S1 disc herniation cause isolated toe sensation abnormalities?
Yes, a herniated disc at the L5-S1 level can lead to sensory changes in the foot, particularly affecting the areas innervated by the L5 and S1 nerve roots. However, the symptoms typically include more than just toe numbness; they often present with pain, weakness, or altered sensations in the lower back, buttocks, and down the leg, potentially leading to sciatica. If your symptoms are isolated to the toe without accompanying back pain or typical sciatica, it may suggest that the herniation is not the sole cause of your symptoms.

2. If disc herniation symptoms are not prominent, what peripheral nerve issues should be considered?
If the symptoms do not align with typical disc herniation presentations, it is essential to consider other potential causes of peripheral nerve issues. Conditions such as tarsal tunnel syndrome, which involves compression of the posterior tibial nerve as it passes through the tarsal tunnel near the ankle, could lead to similar symptoms in the toes. Additionally, neuropathies due to diabetes, vitamin deficiencies, or other systemic conditions could also manifest as numbness or tingling in the toes.

3. Should the symptoms lean towards disc herniation, tarsal tunnel syndrome, or other conditions?
Given that you have tightness and cramping in the calf muscles, along with the altered sensations in the toes, it may be worth considering both lumbar disc issues and peripheral nerve compression syndromes. The tightness in your calf muscles could indicate a neuromuscular issue or even a vascular problem, which could contribute to the sensations you are experiencing. A thorough clinical examination, including a detailed history and physical examination, is crucial to differentiate between these conditions.

4. Can an MRI be arranged to evaluate the lumbar spine and the entire leg for nerve compression?
Yes, an MRI is an excellent tool for visualizing the lumbar spine and can help identify any disc herniations, spinal stenosis, or other abnormalities that may be compressing the nerve roots. Additionally, if there is a suspicion of peripheral nerve issues, an MRI of the lower extremity can also be useful to visualize any potential compression points along the course of the nerves. It is advisable to discuss with your physician the possibility of conducting an MRI that encompasses both the lumbar spine and the relevant areas of the leg to get a comprehensive view of any potential nerve compressions.

In summary, while your symptoms could be related to an L5-S1 disc herniation, the isolated nature of the toe symptoms and the presence of tight calf muscles suggest that other conditions, such as peripheral nerve compression or neuropathy, should also be considered. A detailed evaluation, including imaging studies, will be essential in determining the exact cause of your symptoms and guiding appropriate treatment. If conservative treatments like physical therapy have not yielded results, further diagnostic imaging and possibly referral to a neurologist or orthopedic specialist may be warranted.

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