A 24 year-old woman presented to outpatient clinic with 5 years of worsening lower gluteal pain radiating to her right posterior calf with intermittent numbness. Neuromuscular examination showed ischial tuberosity tenderness and hip tightness. EMG was consistent with chronic right L4-S1 radiculopathy. Lower extremity MRI demonstrated sciatic nerve schwannoma, a grossly complex and multi-lobulated tumor, which was subsequently resected.
At 6-week post-op, she had a right antalgic gait, gluteal and gastrocnemius atrophy, with persistent hip flexors and abductors tightness. She was unable to tiptoe on her right foot as compared to total weight-bearing with eccentric left calf activation. Sensation was diminished in the right posterior calf and plantar foot. She was unable to work and required gabapentin for pain. Due to significant gait dysfunction and focal post-surgical weakness, patient was referred to physiatry and an outpatient PT program was initiated.
After 6-week PT program including low frequency electromyostimulation (EMS), active hip ROM, slow treadmill walking and TENS, notable improvement was observed in manual muscle testing, hip tightness, and the lower extremity functional scale which increased by 75%. At 8-week follow-up, she experienced minimal episodic pain, had discontinued gabapentin and returned to teaching kindergarten. She then transitioned to home program of hip stretching and calf strengthening exercises.
Sciatic nerve schwannoma is rare disorder that can present as lumbosacral radicular pain and mimic hip or sacroiliac joint dysfunction. Management of schwannoma often involves surgery, which poses various complications. Following resection, our patient developed a functional decline with gluteal and gastrocnemius atrophy, weakness, and pain. This case emphasizes the role of therapy with low-frequency EMS, ROM/stretching which were initiated at 6 weeks post-operatively.
Prompt physiatrist evaluation and timely institution of low-frequency EMS with conventional physical therapy, aid in axonal regrowth and maximize function following sciatic nerve schwannoma resection.
Anton Matveev– Resident Physician, Temple University Hospital/ MossRehab
Sean Delany– medical student, Lewis Katz School of Medicine at Temple University
Matthew Roland– medical student, Lewis Katz School of Medicine at Temple University
Cora Brown– Physician, Abington-Jefferson Health