(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 IlioInguinal 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-upper lumbar spine L2-L4, to the foot and can be trapped anywhere along its course.
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
An aside: Diabetes has a predilection for the Quadriceps muscle. Remembering that approximately half of diabetics are 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 (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.
CAUSES OF ENTRAPMENT
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.
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 nose-bleed 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 Ortho 1975 May;(108))
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.
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 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
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 T12-L1 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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