Keywords; femoral nerve, upper leg pain, groin pain, maignes syndrome, meralgia paresthetica.
This is not a highly academic dissertation on neuroanatomy but rather how the mid and upper lumbar spine relates to chiropractic practice.
The upper lumbar plexus supplies five major nerves and some smaller ones, all of which overlap giving off small branches which connect with each other, making the precise diagnosis of the pain patterns difficult.
Fortunately, in chiropractic practice, it's not usually necessary to make a decision whether the entrapment is of the the ilio inguinal or hypogastric, for example. Medicine does it by injecting nerve blocks to determine the level.
The spinal adjustment is determined by the spinal segment involved, rather than the particular fibre. For example, the L2 root could affect three different nerves, not to mention the posterior primary rami.
Determining the level to manipulate is not usually simple; it's based on motion palpation, referral pattern, tenderness, reflex and dermatomal changes as well as any scans if they are available.
Having decided the second lumbar vertebra is the spoke in the wheel, it's not critical to the chiropractor whether the genitofemoral, lateral cutaneous or femoral nerves are involved.
What is vital is knowing that the lateral femoral cutaneous is a sensory nerve and would not affect the quadriceps muscle; also one would need to work in the groin where it is often secondarily entrapped.
However, the femoral nerve is also motor and certainly can and does affect the quadriceps reflex and muscle.
The femoral nerve is the first of two large nerves that supply the leg, the other being the sciatic nerve.
The femoral nerve emerges from the mid to upper lumbar spine, whereas a sciatica originates from the lower back.
Both course down just in front of the spine, through the pelvis, but the sciatic nerve emerges through the greater sciatic foramen, passing into the buttock and the back of the thigh and calf, and the outer side of the lower leg and the foot.
But the femoral nerve passes through the groin supplying the
The femoral nerve is very long, stretching from the mid to upper lumbar spine L2 to L4, to the foot and can be trapped and injured anywhere along its course.
Because it is a mixed nerve, injury to the femoral nerve can cause both sensory disturbance, including pain, and motor weakness of the quadriceps and ilio psoas muscle. Consequently, a marked limp is a feature of the condition. Stairs may become difficult and dangerous.
That altered gait upsets the kinetic chain causing other problems; perhaps disturbing the balance mechanism in the inner ear, or provoking an otherwise silent hip arthritis or capsulities and other seemingly unrelated conditions.
Asides from the chiropractic coalface aren't scientific but they are interesting; diabetes has a predilection for the quadriceps muscle. Remembering that approximately half of diabetics are walking the streets undiagnosed, non painful weakness of the quadriceps muscle, particularly if associated with the typical diabetes symptoms of thirst, weight loss and inability to gain an erection, always calls for a blood sugar test.
More typically the femoral nerve patient presents with pain around the buttock, front or side of the thigh, around the knee, and sometimes down the inner lower leg.
There is often sensory disturbance; early on
increased sensation, but later numbness and, in more serious cases, loss of
the knee jerk reflex and weakness of hip flexion and knee extension. The knee gives way when walking and stairs become difficult.
Weakness of the quadriceps and iliopsoas causes a marked limp.
Both a slipped
disc in the mid lumbar region, and a facet syndrome may cause severe
back pain and radiating pain to the anterior thigh and sometimes lower
inner leg. I have experienced this personally; there was severe pain on the side of the hip with numbness on the inner, lower knee.
When the quadriceps muscle is affected, you may find
that the knee gives or buckles. People may remark that you are limping
badly. Your chiropractor will find a diminished or absent knee jerk
reflex. You can yourself test the muscles in the leg by following the simple instructions in the above video.
Notice the blue, sensory and red, motor, nerves to the quadriceps muscle.
Causes of entrapment
Very occasionally, an abscess, such as in tuberculosis, abdominal tumours and a sudden bleed by patients on anticoagulants may physically press on the femoral nerve causing pain and weakness in the thigh.
An aside which is of some importance; always there's a trade off between the benefits of treatment, and that includes chiropractic help, and the potential noxious side effects. Today I heard that a patient aged 83 couldn't come for treatment; anti coagultant therapy caused a nosebleed so bad that she's been hospitalised. And last month a very special favourite patient, yes, all doctors have favourites, went in for routine laser treatment for an eye condition. The surgeon didn't ask what drugs she was on; the anti coagulants for a minor heart condition caused a bleed behind the retina, and now she's permanently blind in one eye. She's only 55 years old.
Needle puncture procedures, abdominal and inguinal surgery, total hip replacement, harvesting of bone chips from the ilium, a difficult childbirth, pelvic fractures, cancer radiation and other trauma to the groin, knife wounds, for example, and pelvis and upper leg all can occasionally injure the femoral nerve.
Obviously patients with a gunshot wound will not present at a chiropractic clinic, but through the years I have had patients with a femoral neuritis caused by diabetes, after pelvic surgery, after total hip replacement, after radiation to the bladder, as well as the typical lower back conditions that can and do cause pain and weakness in the distribution of the femoral nerve.
Clearly, a thorough case history and examination is vital in all cases of groin and anterior thigh pain.
Hip arthritis too, also typically causes groin pain radiating down the anterior leg to the knee, but with very different signs so that the astute clinician would have no difficulty making the differential diagnosis.
Of 455 patient treated surgically for lower back and leg pain, 10 percent were found to have syndromes affecting the femoral nerve, and 90 percent the sciatic nerve. Ask any chiropractor; nine out of ten cases involve the lower two discs and the sciatic nerve.
Herein lies a danger; the mid an upper lumbar spine is often overlooked as a cause of leg pain.
Interestingly, those with femoral nerve conditions were on average more than ten years older than the sciatic nerve group.
What's the reason? The femoral nerve group, the older patients, had lesions of the facet joint associated with aging and arthritis, rather than disc injuries, which were more common in the younger sciatic nerve group.
Notice that the foramen from which the nerve emerges is bounded anteriorally by the disc on the right and the facet joint posteriorally, left. Both disc and facets can impinge on the nerve roots.
The researcher, Hazlett JW, reported:
Point number 4 above is vital for the Chiropractic physician. A facet syndrome at L3-L4 will affect the L4 nerve root, but the not uncommon far lateral disc lesion at L3-L4 may cause a L3 radiation. Successful treatment is predicated on making the correct diagnosis and treating the correct level.
Like Carpal tunnel Syndrome, Femoral-nerve neuritis is frequently a "double-crush" syndrome, with the nerve being irritated both in the lumbar spine AND the groin, usually distal to the inguinal ligament.
Successful outcomes may be dependent on BOTH sites of impingement being addressed. In short, is your chiropractor also busy in the groin/ upper thigh?
Meralgia Paresthetica is a neuritis affecting the purely sensory lateral femoral cutaneous nerve, again with an impingement in the upper lumbar spine and the groin. It responds well to chiropractic help that is directed at both the spine and the groin.
The quadriceps muscle and the knee jerk are not affected. The numbness, tingling or pain is down the side of the upper leg, and sometimes in the groin too but no motor weakness.
The ilioinguinal nerve supplies in the female the labia and the medial upper thigh/ groin. In the male the scrotum and allied region.
A facet injury at the thoraco lumbar junction can cause pain in the groin and scrotal areas, as well as a maignes syndrome.
Once again, addressing both the spinal lesion and an entrapment in the
groin as the ilio inguinal nerve passes into the inguinal canal may be
important. Treatment should be limited to a maximum of three sweeps across the adductor, hip flexor muscles and the capsule. It's extremely painful, and may leave bruising. Care must be taken when crossing the femoral artery.
Buttock pain is also a feature of Maignes syndrome ...
FEMORAL NERVE CaseFile
Every day there is an interesting
Femoral nerve casefile
walking into the clinic. Lower back and leg pain, upper leg pain, groin pain, Maignes syndrome, Meralgia paresthetica, you name it, every day they present at the Chiropractic Coalface.
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Interesting challenges of the day
1. Mr D has very severe midback back. He bent and twisted, feeding his son, and then laughed. Every breath is a nightmare. A sprung rib is every chiropractor's delight. He or she has golden hands. 30 percent better after one treatment.
2. Mrs C has a long history of severe, disabling migraine headaches since having her wisdom teeth removed. She clenches her teeth at night. After six treatments she has no migraines but some jaw joint discomfort remains; a bite plate is in the offing.
3. Mrs U has the trophy for the worst back this year. After major surgery with plates and screws two years later she still had paresis in the lower leg and severe disabling back pain. She's doing far better than expected, in no little part due to a lift in her shoe for a very short leg.
4. Mr V is 86 years old and hurt his back helping his wife into the car. Just one treatment of the sacroiliac joint and he's eighty percent better. It's not always like that.
5. Mr W lay on his back knocking down a pillar. Turning his head causes severe vertigo. He needs the Epley exercises, not pills, research shows. Update, he's fine.
6. I myself had an acute exacerbation of a femoral nerve lesion last year. One immediate treatment by my colleague has fixed the pain in the lower back, but there's some residual numbness in the lower leg; no soaring tomorrow alas.
7. This lady is a 86 year old woman with a 63 scoliosis. Chronic lower back has been her lot in life but she's well pleased with chiropractic and comes for chiropractic help once a month; some conditions you can never cure.
8. She is an 78 year old woman, is doing remarkably well with a bad sciatica. But over 200 pounds she is not losing weight; in fact, gaining despite my suggestions. She's high risk for a stroke. I have referred her to a dietician to crack the whip.
9. A 61 year old man with upper cervical pain yesterday; it's not severe but also not getting better of its own accord. He's afraid it may turn very acute as when I treated him three years ago. Since then it's been fine.
10. A 64 year old woman has had scheuermanns disease; it's left her with a spinal kyphosis and chronic middorsal pain. She responds well to chiropractic treatment provides she come every six weeks or so for maintenance treatment.
11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.
12. Mrs D, a middle aged woman with hip pain of one year duration, despite other treatment. Xrays reveal an impingement syndrome and early hip arthritis. There's much to be done.
13. Mrs B has had one of the nastiest of conditions; vertigo caused by a disturbance in the inner ear. Falling repeatedly and vomiting she consulted her doctor but medication didn't help. After two sessions of the Epley manoeuvres she was 50 percent better. After two weeks 75 percent improved. No longer vomiting all falling. She's not enjoying the Brandt Daroff home exercises.
And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.
Have a problem that's not getting better? Looking for a different slant on your pain? Want to pose a question?
Greetings, Dr B.
You helped me quite some time back with a soothing and professional response which turned out to be exactly correct. I now consult a local chiropractor. You write a superb newsletter, too.
Your own unresolved problem. Pose a question
Knowing that up to 70% of the time the correct diagnosis is made with no examination, no special tests, no xrays, but just from the history, there's a fair chance I can add some insight to your unresolved problem. But at least 30% of the time, I may be quite wrong! Give plenty of detail if you want a sensible reply.
You visited this chiropractic help site no doubt because you have a problem that is not resolving and want to know more about what chiropractors do.
The quickest and most interesting way is to read one of my ebooks of anecdotes. Described by a reader as gems, both funny and healthful, from the life and work of a chiropractor, you'll love them. Priced right at $2.99, though Kindle fiddles the price without telling me.