(Keywords: FEMORAL NERVE, femoral neuritis, lower back and leg pain, 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 Help 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 femoral nerve or the ilio inguinal nerve, for example. Medicine does it by injecting nerve blocks - if the pain stops, then it must have been the xxx nerve.
Femoral nerve (L2-L3-L4)
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-upper lumbar spine, whereas the Sciatic nerve emerges from the lower lumbar spine.
Both course down just in front of the spine, through the pelvis, but the Sciatic nerve emerges through the 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 limp 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.
An aside from the chiropractic coalface; 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, often sensory disturbance, early on
increased sensation, later numbness and, in more serious cases, loss of
the knee jerk reflex and weakness of hip flexion and knee extension. The knee gives. 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.
Causes of entrapment
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.
Very occasionally, an abscess, such as in TB, 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: 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. 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.
INTERESTING RESEARCH Clin Orth 75 May
Of 455 patient treated surgically for lower back and leg pain, 10% were found to have syndromes affecting the femoral nerve, and 90% 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.
The reason? The femoral nerve group, the older group, 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.
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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 B has the trophy for the most acute neck in February. He has quite advanced lower neck arthritis for a forty year old, thanks to a severe fall on the head from a trampoline. But this is upper cervical pain. Right rotation is simply impossible. Luckily he is improving rapidly, eighty percent better he says after three treatments. See cervical facet syndrome.
2. Mrs C is a new patient with a long history of lower back pain, hip pain and pain in both feet. We'll see how we get on, Rome wasn't built in a day.
3. Miss U sprained her ankle two months ago, wearing high heels. She still has severe mid foot pain. Xrays and perhaps a CT scan.
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. Mrs X, a young mother has severe lower back pain, with numbness down the posterior thigh, calf and side of foot. It started after a long drive in the car. Update, she's forty percent less painful after four treatments, but the leg is still numb. Update two; she 60% better, but it's slow and is going to take the full 6 weeks to heal. Further update; a setback, after lifting her child she now has leg pain. It's going to the be difficult.
7. Mrs Y, a 70 year old woman is on maintenance care fo a nasty lumbar stenosis despite having to do everything at home. Her husband has a hospital acquired infection in the shoulder. After 4 operations he is incapacitated and going rapidly down hill.
8. Mrs Z, an 78 year old woman is doing remarkably well with a bad sciatica. But at over 200 lbs she is not losing weight, in fact gaining despite my suggestions. She's high risk for a stroke. Referral to a dietician to crack the whip.
9. Mr A, a 73 year old engineer, still working, is doing fine after a long episode of lower back pain. Some pain on the side of the hip remains after five treatments. Reassured him it's not hip arthritis.
10. Mrs B, a 64 year old woman has had Scheuermanns disease; it's left with a spinal kyphosis and chronic middorsal pain. She responds well to chiropractic treatment, provides she come every six weeks or so for treatment.
11. Mr C, a young engineer fell off his mountain bike injuring his cervical spine and pelvis. Luckily both responded very quickly to a few chiropractic adjustments. Update: his neck is sore again. It all goes back to a whiplash injury ten years ago when he was rammed by a fully laden truck carrying a load of stone. Time for Xrays.
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. Both Mrs E and I can't believe how much better her lower back and leg pain are. Surgery for a scoliosis and spondylolysthesis three years ago helped greatly for one year. But then her leg went lame and weak. He was responded extremely well despite all expectations.
And so the day goes. Chiropractors shouldn't be treating the elderly? 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.