(Keywords: pain in upper leg, chiropractic help, Femero Acetabular Impingement syndrome, upper leg pain, Maignes syndrome)
Mrs V (63 years) has had left low back pain for about ten years. There was no obvious cause. One year before her first consultation (July 2009) severe pain began in the left groin, radiating down the front of the thigh towards the knee. Periodically her upper left leg would suddenly 'give', partly with a sharp stab of pain, and partly due to a weak feeling. Frequently she could barely walk, the pain in her upper left leg was so bad.
She wore a heel lift in her RIGHT shoe; that brought some measure of relief.
Treatment by an orthopaedic surgeon specialised in manipulation brought some relief of pain, especially the insert in her shoe, but her leg continued to buckle under her, and walking remained very difficult. After several months, this doctor referred her to our clinic for evaluation.
On Examination @ Pain in upper leg
In bare feet, it was clear that she had a very short RIGHT leg, a sharply tilted pelvis, low RIGHT, and accompanying scoliosis, convex right. Or, was it left? Was I going crazy, the X-rays told a completely different story.
Ranges of motion of the lumbar spine were good, without radiation of pain to the leg, or significant pain in the back.
Left hip: Flexion and rotation (internal and external) rotation were full, and without pain. Thus, no hip arthritis. However, adduction, pulling the knee towards the opposite shoulder caused sharp pain in the groin.
The test called Patrick's Faber test, was also strongly painful and some movements were limited in the groin. Hip arthritis? Femero Acetabular Impingement Syndrome?
Most odd, was that the Slump test provoked pain in the front of the thigh - it's a test for the Sciatic nerve which, when pinched or irritated, would cause pain down the back of the leg. In that sense, the Slump test for sciatica was negative.
However, the Femoral nerve stretch test was positive, with pain in the front of the left thigh. A pinched nerve, either in the groin or lumbar spine? Upper leg pain always calls for careful examination.
Neurological examination of pain in upper leg
Once again there were contradictory results: The reflexes were normal and there were no sensory changes, but the Quadriceps muscle was weak - the probably the cause of her leg suddenly giving under her weight, particularly on the stairs. Unusual with a normal reflex.
Chiropractic Help examination
She stood very prominently with a short RIGHT leg, and attendant scoliosis. There were fixations in the right sacroiliac joint anatomy, and at the L1 joint.
With groin and pain in upper leg (front of leg), the involement of the Femoral nerve and a possible Maignes syndrome was high in my list of differential diagnoses of upper leg pain. Sacroiliac joint anatomy ...
There's no mention whether this X-ray of the pelvis was taken standing, or lying supine. That's important when making decisions about a heel lift. The strong implication here was very short LEFT leg.
Was I going crazy? I have got it wrong before, and sometimes an apparent short leg can change after treatment of the pelvis. So, a phone call to the hospital. Indeed, the radiograph was taken lying supine. It was just a bad set-up by the radiographer.
This whole case is loaded with difficulties.
Following the Thompson drop protocol we adjusted the sacrum on the right, L1 on the left with the so-called "million dollar" roll.
The left hip was mobilised and the Adductor magnus, pectineus and psoas with treated with the Active Release Technique (extremely painful).
A vigorous rehab programme.
Mrs V consulted me again today. She comes with her husband once every six weeks.
She's a very happy lady, but I'm still confused. She can walk long distances without her leg collapsing under her, and without pain in her thigh. But I still don't confidently have the correct diagnosis. Many years ago I learnt an important lesson from Dr Glynn Till, president (now retired) of the Chiropractic College in Durban, South Africa.
"Remember, the patient may have two different conditions."
Dr G. Til, DC
Femoro Acetabular Impingement Syndrome
Pain in upper leg
The "spot" of her left hip reveals little arthritis superiorally to speak of, mild signs of Femoro Acetabular Impingement Syndrome Pincer and CAM, and several unnoticed cystic lesion in the ball of the femur.
It's time for new X-rays and, depending on the result, an MRI. X-rays of her lumbar spine, taken standing WITH the heel lift in place in the right shoe, and a new spot of the left hip. And a test for Diabetes.
That diabetes test is just routine. I'm not expecting it to be positive. She is not obese, there is no urinary frequency, no loss of weight, no abnormal thirst and, when a diabetic neuropathy causes weakness in the Quadriceps muscle, there's no pain in upper leg usually. Silent and deadly.
Like all case histories, this case is in development, and will always remain in development. She thinks the future is rosy, I have unanswered questions. Meantime, she walks, she does her back and pelvis rehab exercises, she's happy... they are off hiking in the Black Forest in the south of Germany this week. Life is full...
Another difficult Pain in Upper Leg
Mrs S came for treatment for terrible headaches. An elderly woman, I was shocked at how many analgesics she was taking. Rebound headache is actually caused by taking bucketfuls of pills...
There was nothing simple about her upper neck headaches, but they have now stabilised at about 80% better and she needs little medication.
The problem is that she is always very sore for about three days after an adjustment. So now she comes once in two months, and is very happy.
But her upper leg?
After an operation to remove a sickly ovary she developed severe pain in the groin and upper thigh. I suspected they knicked a branch of the Femoral nerve and there was little to be done. But she did have a L2 fixation - the Femoral nerve comes from the upper lumbar spine.
As with her neck, she was VERY sore in her lower back for three days, but hey presto, no more restless legs at night, no more hanging the leg outside the blankets, no more pain. And she does her lumbar exercises very faithfully.
Health is additive. The positives and the negatives. This lady has been has heavy as 160kg, now 117kg has a double spondylolysthesis (old trauma most likely), has Femero Acetabular Impingement Syndrome and severely arthritic knees. An interesting case: Pain and tingling in feet and legs Casefile...
Useful links @ Pain in upper leg
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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.
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